Safety Critical Communications

Guideline
 Safety Critical Communications

Notice to Users
This RISSB product has been developed using input from rail experts from across the rail industry and
represents good practice for the industry. The reliance upon or manner of use of this RISSB product is
the sole responsibility of the user who is to assess whether it meets their organisation’s operational
environment and risk profile.

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Identification

Document Title Version Date

Safety Critical Communications 1.0 31 January 2018

Document History

Publication Version Effective Date Reason for and Extent of Change(s)

First version 31 January 2018 First Published

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© RISSB
All rights are reserved. No part of this work may be reproduced or copied in any form or by any means,
electronic or mechanical, including photocopying, without the written permission of RISSB, unless
otherwise permitted under the Copyright Act 1968.

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Contents
Introduction............................................................................................................................ 4
Purpose ......................................................................................................................... 5
Scope & Application ...................................................................................................... 5
Definitions ..................................................................................................................... 5
References .................................................................................................................... 6
Safety Critical Communications - General ............................................................................. 7
Introduction ................................................................................................................... 7
Contribution to Incidents ................................................................................................ 7
Communications – a Model ........................................................................................... 7
Error Types in Communications..................................................................................... 9
Communication Failure Contributing Factors ................................................................. 9
Work Environment and Equipment .............................................................................. 12
Safety Critical Communications – Strategies for Management ............................................. 13
Responsibilities ........................................................................................................... 13
Recruitment and Selection Processes ......................................................................... 14
Rail Safety Critical Communication Protocols .............................................................. 14
The Lead Communicator ............................................................................................. 16
Training and Competence ........................................................................................... 16
Assessment ................................................................................................................. 19
Active Listening ........................................................................................................... 19
Audits and Threat and Error Management (TEM) ........................................................ 20
Communication Task Aids ........................................................................................... 22
Recording of Communications ..................................................................................... 22
Safety Critical Communications Equipment ................................................................. 23
Written Safety Critical Communications ....................................................................... 23
Hand-Signals ............................................................................................................... 24
Appendix A Safety Critical Communication Procedure ................................................... 25
Appendix B Emergency Communication Protocol .......................................................... 27
Appendix C Standard Terms .......................................................................................... 28
Appendix D Phonetic Alphabet ....................................................................................... 29
Appendix E Spoken Numbers ........................................................................................ 30
Appendix F The 24-Hour Clock ...................................................................................... 31

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Introduction
Safety Critical Communications are an integral part of the safe and efficient operation of rail networks
around Australia.
A goal of the Australian rail industry is for rail traffic to move safely, efficiently, and effectively within
and between networks and ensuring the protection of all rail personnel.
Communications have long been known to be a key contributory factor in safety incidents in general.
The railways are no exception as evidenced by a number of studies in the UK (Lowe & nock 2007, ORR,
Dickinson 2008, Shanahan et al., 2007). The exact number is subject to considerable variance (ranging
from 90% - 30%) given the number of other contributory factors at play in most incidents. More recent
studies in Australia indicate a similar variance.
Even given the variance in these studies and their conclusions, there is no doubt that effective
communication plays a crucial role in ensuring safety. Communication is a major part of good working
practices and systems, particularly where people are distributed throughout a geographically spread
environment with constantly changing risk in the form of moving rolling stock and highly mobile work
forces.
The term ‘Safety Critical Communications’ is included in the ‘Definitions’ below. However, this guideline
seeks to ensure that all users recognise that the practice of good communications should be extended
to cover a range of other areas including (but not limited to) the following activities:
• Emergency situation communications;
• All ‘Safeworking’ communications including (but not limited to):
– Proceed Authority;
– Work on Track Authority;
– Train Running Information;
– A Condition Affecting the Network.
• Pre-Start Briefings;
• Permit to Work (e.g. Electrified Territory);
• Shift change handover information;
• Safeworking documentation and logs.
The consideration is whether the result of a failure in communication and the message being
transmitted by whatever medium, such as radio, telephone, signal or writing, could result in an incident.
In addition, it should also be considered that where a reason for communication can originate from a
‘non-safety critical’ situation, there is potential for any miscommunication to evolve into a safety critical
situation. For this reason, it is recommended that all communication processes follow the protocols
contained in this guideline at all times regardless of the reason for the communication.
Another advantage of ensuring the formality of communication at all times, is that it will aid in ensuring
that the persons who are communicating maintain consistency. This means they always use the same
language structure and there is no need for them, ‘in the heat of the moment’, such as an emergency, to
be considering which communications protocol to be using.

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Communication, good or bad, is one of the most fundamental of the ‘human factors’, and as such it
needs to be considered carefully in this respect and examine what can go wrong and strategies to
mitigate the failures.

Purpose
The purpose of this guideline is to consider the aspects that result in failed communications and to
establish a range of guiding principles to assist in mitigating the risk of such failures by providing Rail
Transport Operators (RTO’s), and associated rail industry stakeholders, with a range of processes and
practices they can adopt and use for their operations.
This Guideline is outcome focussed, rather than being prescriptive in nature. It does not seek to
mandate particular systems, processes or technologies, but focuses on outcomes, leaving the method
up to individual network managers.

Scope & Application

The scope of this Guideline includes all rail safety work where the communication of information to and
between persons is required in order to ensure the safe operation of the railway. This includes but is not
limited to:
• Track works;
• Train operations;
• General Safeworking activities; and
• Shunting
The practices set out in this Guideline are applicable to all entities working in the Australian rail industry.
This includes all RTO’s and their contractors whose personnel engage in any form of communications as
described above.
It is intended to apply principally to verbal/audio communication such as via telephone, radio and face-
to-face, but it also addresses some aspects of other communication mediums carried out in the railway
network and includes:
• Hand signals and semaphore; and
• Written e.g. safeworking documents etc.

Definitions
All definitions in this document, other than those specifically listed below, are as per the RISSB Glossary
of Railway Terminology for general railway definitions.
Authority Gradient: The perceived difference in status between different members of an organization. It
is a barrier to effective communication and a potential source of interpersonal resentment and
organisational error.
Communication: The sending and receiving and understanding of information from one place or
individual to another.
TEM: Threat and Error Management – a safety management approach originating in the aviation
industry. TEM recognises that operators will naturally make mistakes and encounter risky situations
during operations and focuses on teaching operator’s management strategies to prevent unsafe
outcomes.

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Safety Critical Communications: Is any communication that, if not delivered or not delivered accurately
or promptly, could result in death, serious injury or incur significant damage to property, infrastructure
or the environment.
Train Safety Recording: (refer RSNLA s130) means a recording consisting of (or mainly of) sounds or
images or data, or any combination of sounds, images or data, produced by a device installed in a train,
signal box, train control complex or other railway premises for the purpose of recording activities carried
out by rail safety workers in relation to the operation of a train.
Phonetic Alphabet: A standard set of distinct codewords that correspond to the letters of the English
alphabet so that each letter is clearly distinguished from every other letter and will be commonly
understood by parties exchanging information regardless of language, accent, sound quality etc. (Also
referred to as the ICAO phonetic alphabet or International radiotelephony spelling alphabet.

References
All RTO’s are to ensure that relevant standards, Original Equipment Manufacturer (OEM) documentation
and other relevant guidance are taken into account when establishing their specific systems and
processes for their safety critical communications.
The following references were utilised in the development of this guideline:
• The Rail Safety National Law;
• ANRP 2007 Network Communication:
• ANRP 2008 Spoken and Written Communication;
• ONRSR Guidelines for Rail Resource Management – National Rail Resource Project (Lowe
A.R., Hayward, B.J., & Dalton, A.L.)
• Human Error in Railway Operations Control – Interfleet (C. Williams);
• Literature Review of Safety Critical Communication Methodologies – Study on safety
related communications methodology – Interfleet (K. Dobson, A. Moors and B. Norris 2014)
• Threat and Error Management Presentation – ATSB (I. Banks);
• RSSB RIS-8046-TOM Spoken Safety Communications;
• RSSB TO14 Research Program Operations – Safety Critical Communications;
• MTM LO-SQE-PRO-032 Safety Critical Communications;
• Shanahan P., Gregory, D., Shannon, M. and Gibson, H., 2007, The role of communication
errors in railway incident causation;
• HSE Preventing Person to Person Communication Failures in the Operation of Nuclear
Power Plants 1998.

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Safety Critical Communications - General

Introduction
This guideline has been developed by the RISSB in co-operation with the Australian Industry Standards
(AIS). Its purpose is to provide a guideline giving understanding into ‘Safety Critical Communications’.
What it is, what goes wrong and why and finally provide some strategies and processes to aid RTO’s and
other rail industry stakeholders, in ensuring communication processes are correctly managed.
Safety critical communications are carried out as a normal part of everyday operations in the railways.
They are a fundamental part of controlling and operating trains, track maintenance vehicles and working
activities throughout the network.

Contribution to Incidents
That communications, or the failure thereof, contribute to incidents is not doubted. The exact extent is
not accurately established but studies put the rate at approximately 30% across all incident events, with
something in the region of 50% in relation to all track work incidents.
Within Australia, one major rail network carried out their own studies and they found that, in an
examination of their incidents, a significant number of all incidents had communication as a root cause.
The main factors contributing to these incidents comprised of:
• Lack of Communication;
• Poor Communication; and
• Incorrect Information being passed on.
All of this, provides clear evidence that there is a direct causal link between communication and
incidents on the railway network.

Communications – a Model
All communications can be misinterpreted. Most misinterpretations are of no or little consequence and
are readily self-remedied by the parties to the communication. With safety critical communications
however, the consequences can be significant. It is important therefore to understand the process of
communication and from this the potential errors can be identified, and controls established and
implemented.
The diagram below shows a simplified model of communications. The model shows each of the key
steps in the communications process. Understanding this process aids in identifying and implementing
strategies and processes to mitigate the risks of failure in the communication process.

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Diagram 1 - Simplified Model of Communications (refer HSE 1998)

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Error Types in Communications

The model described above allows for the basic errors in communication to be identified. The main
communication error types are as below (refer Shanahan 2007):
• No communication
• Wrong information given
• Incomplete information given
• Wrong timing of the information
• Unclear communication
• Badly expressed information
• Misheard message
• Did not listen to communication
• Failure to reach common understanding of information
• Reach common but incorrect understanding of the information

Communication Failure Contributing Factors

There are two significant factors (barriers) which contribute most strongly to influencing communication
error (refer Flin et al 2008). They are:
• Internal factors that are attributable to the person;
• External factors that are attributable to the immediate environment.
These factors may be broken down as described in the table below;

Internal External

Language differences Noise

Culture Interference or distraction

Motivation Priorities

Expectation Separation in location, time

Experience Lack of visual cues

Prejudice Noise

Status Interference or distraction

Emotions/needs Priorities

Hearing ability/deafness Separation in location, time

Voice level Lack of visual cues

Expectation Noise

Although not stated in Flins original work, it is reasonable to also consider aspects in respect of the
‘organisation’ and ‘equipment’ that can also be placed under the ‘external’ factors heading. These items
are discussed further later in this guideline at items 2.5.2 and 2.6.

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5 Key Elements of Communication Error

The ‘Sender-Medium-Receiver’ Communication Process
If persons do not, or are unable to fully understand and decide on what information is or is not
important, such as during a ‘handover’ to a new shift, or relieving supervisor, or even at a pre-start
briefing, there is a risk that they will fail to accurately decide on what information is important to pass
over. For this reason, it is important to make sure that the correct form/type of communication process
(medium) is used and is relevant to the needs and environment. If this is not best suited then there is a
risk that breakdowns in the process can occur
The Communication Process Goals
Comprehending why the communication is being undertaken and what is the communicator is seeking
to achieve is vital. For this to occur it is important that the parties to the communication process
understands what the other party is doing or seeking to do, and the information they need to carry out
that process. Where the sender or receiver makes incorrect assumptions, there is a risk they do not
convey the right message.
The Communication Process Language
Language is arguably the most important part of successful communication. Generally, the pace of the
communication is always set by the sender. This is especially important in the case of an emergency
where the situation could be escalating or there are injuries and people are under stress and
consequently speak quickly, which can result in miscommunication. Similarly, the use of words that can
have several interpretations, acronyms and the use of redundant words can result in communication
failure. In addition to this, communication failure may result from one of parties communicating having
a pronounced language accent or impediment that is exacerbated under stress.
The context of communication
In situations where the sender of the message has succeeded in ‘priming’ or making the recipient
sensitive to the message(s) they are about to receive, greatly increases the chances that the
communication process will be successful. This increases the receivers understanding of the context of
the message and more cognizant of the information necessary for what the sender needs to achieve.
Therefore, the more aware the sender can make the recipient, the less likely the communication will
fail.
Individual factors
Personal (individual) factors can affect the likely success or failure of the communication. This includes
such factors as:
• Stress;
• Fatigue;
• Age;
• Cultural aspects e.g. accents, societal influences etc.
All, or any, of these factors can significantly impact on the effectiveness of communication. There is
evidence that shows team working assists communication and also can combat the effects of fatigue.

Organisational Factors
The corporate culture and organisational factors must not be underestimated for their impact on
effective communication. The UK RSSB carried out a survey of nearly 2500 UK railway staff who
identified the perceived influences on the quality of communication, and these included issues such as

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peer pressure and the example set by management, rather than the formality of communication itself
(RSSB, 2008).

Cultural Aspects
The Authority Gradient
The organisational culture impacts on the way that people interact and communicate with each other.
One such cultural factor important for communications, and which has been implicated in some serious
major fatality incidents, is known as ‘authority gradient’. The Authority Gradient refers to the
established, and/or perceived, command and decision-making power hierarchy in a Team, Crew or
Group situation, and how balanced the distribution of this power is experienced within the Team, Crew
or Group.
A ‘steep’ authority gradient is one in which the ‘leader’ holds a position well above other team members
(in terms of actual or perceived power). The leader is clearly in charge, tells others what to do and does
not encourage the team to contribute. The leader is viewed as dominant and dictatorial and it can
therefore be difficult for subordinate staff to express concerns, question decisions or even clarify
instructions. This can pose a barrier to team involvement and problem solving and can pose safety risks
if critical communications and concerns are not received.
A ‘flat’ authority gradient on the other hand, is where the leader is barely distinguishable from others in
the team and are equal in apparent status and authority. The leader involves the whole team in decision
making (regardless of their experience). This is also a risk as decision making can be slow and may not be
appropriately based on experience.
The ideal authority gradient is between these two extremes. The leader is in charge, but works
effectively with their team members (e.g. consulting them and asking for their ideas). Ideally, it is fluid,
becoming steeper or flatter depending on the circumstances.
Organisations must seek to establish whether such authority gradients exist and if so, how they can be
managed effectively.
Assertive Communication
As noted, an authority gradient that is too steep can actively dissuade those who perceive themselves to
be lower in the organisational hierarchy from challenging information or requesting clarification from
those seemingly higher in the hierarchy. However, there are also other reasons that operators may not
‘speak up’, including:
• Fear of the other person e.g. physically, alienation, exclusion etc;
• Fear of embarrassing themselves or others;
• Lack of confidence / fear of being wrong;
• Assuming someone more experienced will speak up if it is an important matter;
• Previous negative experience;
• Personality of the person involved;
• National cultural/ethical values (that may inhibit some from speaking up to people in
authority or of a higher age group).
Organisations must also seek to empower individuals to communicate assertively about safety concerns,
and provide an environment that supports them when they do.

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Work Environment and Equipment

Other major influencing factors in communications is the effect of such crucial items as:
• Equipment (i.e. radios, telephones etc);
• Environment (i.e. office, on track, in-cab etc);
• Technology (i.e. computers, tablets, speech to text software and similar); and
• Noise i.e. other persons talking, work in background etc;
The standard and quality of all communications systems is fundamentally dependent on the standard
and quality of the radio-telephonic systems being utilised. Similarly, the amount of background noise
and other distractions, including other people, in the location the communication is originating from, or
being received at, will have a significant impact on comprehension of the messages being
transmitted/received.
The rate of progress and change in train control systems and changes in communications technology,
particularly with digital systems, means that it is important that communication procedures and
protocols evolve with such developments. Future technologies in digital and web-based
communications have the potential to greatly enhance and support communication efficiency and
accuracy, but if poorly conceived or implemented could lead or add to confusion.

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Safety Critical Communications – Strategies for Management

Responsibilities
All of those involved in safety critical communications have responsibilities and accountabilities to
ensure that all that can be done ‘So Far As Is Reasonably Practicable’ (SFAIRP), is done to ensure the
communications are effective and protocols are correctly followed.
It is well established in safety management that fundamental shifts in behaviours or performance, like
the link between correctly following communication protocols to reduce incidents, must involve senior
management commitment, leadership with strong safety values and strategies for all aspects of safety
critical communications.
This requires that all those involved in the communications chain must have clearly defined roles,
responsibilities and accountabilities. The following are ‘generic’ responsibilities applicable in all
organisations. Note that in all organisations there may be further items that require to be added.

Managers
All managers have responsibility to ensure that they:
• Ensure that communications performance is checked, monitored and reported;
• talk face-to-face with the workforce about communication concerns, behaviours and
performance;
• Ensure adequate resources and training are in place to achieve effective communication
practices;
• Take action to address communication concerns and poor practices; and
• Recognise and reward effective communication practices and performance.

Superintendents/Supervisors
All Supervisors have responsibility to ensure that they:
• Check that the team complies with communication protocols;
• Encourage team members to speak up about communication issues;
• Coach and mentor the team to improve communication protocols;
• Address poor communication practices fairly, firmly and consistently;
• Recognise and reinforce effective communication practices in the team; and
• Initiate discussions with the team about communication practices.

All Personnel Engaged in Communications

All personnel who are required to undertake communication processes have a responsibility to ensure
that they:
• Learn and follow the communication protocols;
• Report communication issues and any conditions that impede effective communication;
• Give support and advice to team members to improve communication practices; and

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• Participate in discussions and investigations to improve communication practices.

Safety and Compliance Personnel

Personnel engaged in safety and compliance roles e.g. Safety Management roles, Auditors etc. Have
responsibilities also in relation to communications. They are uniquely placed, as appropriate jointly with
line management roles, to conduct and/or assist with carrying out such functions as:
• Preventative inspection/assurance activities;
• Adopting an educational role e.g. Toolbox topics;
• Raising awareness e.g. safety alerts;
• Audits of voice communications;
• Assess adequacy of communications management systems e.g. application of risk
assessment tools; and
• Analyse the role of communications in incident investigations and their potential for
causing/exacerbating human errors.

Recruitment and Selection Processes

Communication skills are the skills needed to use spoken and/or written language to interact with
others. The primary skills are reading, writing, listening and speaking. These skills enable people to share
information, ideas and feelings and to transfer meaning among themselves. These factors are the
essence of effective communication.
Arguably the first step in ensuring effective management of safety critical communications is at the
recruitment and selection process. All organisations should ensure that there is in place a recruitment
and selection process that tests and ensures only those persons with satisfactory verbal and written
communication skills are engaged in those roles where such skills are necessary.
Such testing may be carried out using such tools as Cognitive Ability Tests and also Behavioural
Simulation Exercises. These assessments measure a variety of abilities, such as verbal and mathematical
ability, reasoning ability and reading comprehension. Cognitive ability tests have been shown to be
extremely useful predictors of job performance and thus are used frequently in informing selection
decisions for many different types of jobs.
Note that this does not mean that persons who have some difficulty with verbal or written skills should
not be engaged. Where such persons have demonstrated that they are clearly otherwise capable and
competent then some ongoing support after engagement will produce personnel able to satisfactorily
fulfil these safety critical functions.

Rail Safety Critical Communication Protocols

General
The model of communication shown earlier in Diagram 1 and the communication failure types and
contributing factors show that there are opportunities for verbal/audio communication errors to occur.
A key strategy to assist in mitigating these risks is for RTO’s to establish standard Rail Safety Critical
Communication Protocols (RSCCP). The RSCCP structure should include processes for the following
aspects as a minimum:
• Communication Fundamentals;

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• Emergency Communications;
• Lead Communicator;
• Standard Language/Terms;
• Use of Phonetic Alphabet;
• Use of Spoken Numbers; and
• Written Communications.

Fundamentals
The establishment of some fundamental principles is critical to good communications. The following
fundamental principles are recommended to be applied to all communications, safety critical or not:
• Plan what you intend to say;
• Provide accurate, brief, and clear messages;
• Give messages in short complete phrases – where practicable establish ‘standard phrases’
(refer Appendix C);
• Talk slightly slower than in normal conversation;
• Speak slightly louder than in normal conversation, but avoid shouting;
• Avoid using redundancies such as ‘like’ ‘y’know,’ ‘er’, ‘yeah-nah’ and ‘um’;
• Avoid interrupting or speaking over the other party;
• Avoid unnecessary repetition;
• Avoid rushing or slurring words;
• Where practicable, avoid the use of acronyms and words with alternative meanings, such as
the word ‘Right’, or an affirmative word for a negative response, such as ‘No, OK’, but do
use common technical terms used in the industry;
• Use ‘active’ language. For example: ‘Ensure that you call Train Control’ rather than ‘Train
Control must be contacted’. In the second instance, it is not stated who must carry out the
action;
• Ensure that the message has been understood – require the recipient repeat back the
message if not already done by them;
• All radio communications should the protocols described in the Appendices irrespective of
the type of radio channel in use.

Limitations and Appropriate Use

In general, there are four aspects in relation to successful communication. They are:
• the technical content;
• compliance to rules and procedures;
• the language used; and
• the context.

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Formal, structured communication, as described above, supports the minimisation of some types of
error such as the omission of information and provides a framework that helps to align both the
sender’s and receiver’s mental models.
However, there are some limitations in the use of formal communication. This includes the following:
• It may not be practical in high pressure environments such as emergency situations where
the need to speak quickly may be significant;
• Personnel often do not appreciate or understand why formalisations are necessary; and
• In less pressured circumstances people naturally revert to familiar/informal styles of
communication as it is more natural. They also do it as a natural part of personal working
relationships.
An ideal communications process will therefore have a balance between formality and informality. A
strict regime of formal, standard phrases and structure to be used for emergency or high-risk scenarios,
with slightly relaxed and less formal communication for routine communications. Noting however, that
both types of situation require fundamental communication protocols to be followed.

The Lead Communicator

All RTO’s should ensure that their safety critical communication protocols include the requirement for a
‘Lead Communicator’. As the title of the function suggests, during any verbal communication, the Lead
Communicators function is to take the lead.
Being the Lead Communicator involves:
• Following a defined communication protocol, such as the one outlined in the Appendices of
this guideline (or the RTO’s equivalent);
• Asking questions when appropriate to ensure that all of the information is available at hand
to make an informed decision on the correct course of action;
• Challenging poor communication style of others and prompting the other party to use the
protocols;
• Ensuring all parties remain calm and composed, recognising and managing any distress,
agitation or stress that might impact the effectiveness of the communication; and
• Concluding the conversation appropriately by summarising and/or ensuring the other party
is clear about what is required.
The Lead Communicator is typically determined by the person’s role. The respective RTO’s will require
to establish this hierarchy within their own organisations based on their own particular structures and
functions.
If it is not clear who is the Lead Communicator, or if two people in the same role are communicating
with each other, the person who initiates the conversation takes the lead.

Training and Competence

General
All personnel should receive initial training in the protocols that the RTO has in place for safety critical
communications. Training must focus not just on the technical aspects of communication, such as the
use of key phrases or the phonetic alphabet or compliance with procedures, but also on the non-

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technical aspects of communication, including the principles identified in 2.5.1, 3.4 and the section
below. Such training should be instructed initially and then provided via an ‘on-the-job’ process.
All the training and competence assessment processes should have, as a minimum, the following
features in the most suitable combination as is most suited to the RTO’s operations and business:
• The communication protocols contained at the appendices to this guideline and any local
RTO supporting procedures;
• The conduct of practical exercises, such as role play or simulation, to give practice and
feedback in a non-stressful situation and enable errors to be corrected in a low risk
environment;
• Where practicable use the actual communications equipment that will be used so that
correct operation of equipment can be practised, and staff can become familiar with any
specific features of the systems;
• Where relevant enable practice in the particular communication protocol(s) that is to be
used for the particular types of equipment;
• Review and examine case studies of actual incidents where assumptions and lack of detail
have led to miscommunication to illustrate why the protocols are necessary;
• Review actual examples of effective use of protocols periodically; and/or
• Encourage self-evaluation and establish peer review processes to assist personnel to
monitor their own and others’ communication performance.
Where practicable it is strongly encouraged that RTO’s should make the training available to its
contractor(s), rolling stock operators and other rail industry participants interfacing with the RTO and
who may be required to carry out safety critical communication processes.
Consideration should be given by RTO’s into the need and extent of refresher training for key safety
critical functions.
Rail RTO’s should put in place suitable non-disclosure and non-publication arrangements to protect
individuals from illegally or inappropriately publishing material that has been derived from this process.

Cultural
The aspect of authority gradient has previously been identified as an area that can cause failure or
degradation of communication effectiveness. All RTO’s should have in place strategies for implementing
and maintaining a ‘Just Culture’ environment. This is one of the key elements of the RTO’s SMS. This
‘Just Culture’ should be supported by processes to assist in ensuring that all communications can be
conducted in a forthright manner without fear of repercussions.
Nevertheless, there remains the risk that even with such a culture the ‘authority gradient’ can still exist
or be perceived. One possible method of assisting in the prevention and management this aspect is
training.
Reducing the risks that arise from inappropriate authority gradients is a matter of raising awareness,
learning some simple skills, practicing those skills whilst under training and applying those skills during
routine and emergency operations. It is also essential, after each of these stages, to openly discuss any
issues that have arisen and to feed these back into the training programme.
Senior managers must be capable of creating a working climate where subordinate team members are
confident enough to raise concerns, question decisions and also offer solutions. This requires the

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development of a flexible and professional leadership style based on clear communication and
encouragement.
Team members need to learn assertiveness techniques to provide them with the confidence to question
authority and play a full part in the team task. A useful strategy to teach personnel is a graded
assertiveness model. Several models of this type exist, including the ‘Probe, Alert, Challenge and
Emergency’ (PACE) approach:
• Probe – “do you know that…?”
• Alert – “Can we re-assess the situation…?”
• Challenge – “Please stop what you are doing while...”
• Emergency – “STOP what you are doing!”
The use of such a graded approach to the communication process assists persons with managing
another person’s perceived or actual authority. This approach should be supported by the person
seeking to question being:
• Assertive – without being aggressive;
• Clear and direct – think about what you want to say and say it;
• Stick to the facts – don’t speculate: and
• Speak for yourself.
Personnel in supervisory or management roles should also be trained to respond appropriately to
concerns expressed by others, and should be encouraged to create an environment where others will
feel free to ‘speak up’ about safety concerns. This includes directly encouraging others to speak up and
ask questions if they are unsure, and responding positively when concerns are raised, or questions are
asked.
In addition to the PACE process above, appropriate and comprehensive pre-task briefings are essential
to clarify roles, responsibilities, capabilities, limitations and boundaries, both in normal and abnormal
conditions. These may need to be reinforced during briefings in relation to unusual or exceptional
situations such as emergencies or where ‘high risk’ tasks are to be carried out.
All RTO’s are encouraged to ensure that this training is supported by a clear policy and that personnel
who find themselves facing such a situation understand that the organisation supports this process.
Additionally, the organisation will not consider such challenges negatively where carried out in
compliance to this structure.

Verbal Communication Procedures

RTO’s need to ensure that they have robust training and reinforcement processes in place for their
verbal communication protocols (refer appendices). Several studies have found problems with the
usability of the protocols. It was reported that personnel found difficulty applying them consistently
and that they were ‘cumbersome’, particularly where significant amounts of information were being
relayed between the parties.
The main features found in the studies included the following;
• Standard words and phrases in the Rule Book(s) were not adhered to;
• The use of the formal terms as „state your message‟ were not used as people felt it to be
impersonal/rude;

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• Use of the phonetic alphabet and single numbers appeared generally satisfactory and well
used;
• Read backs were primarily only done for information if it was considered necessary to avoid
a misunderstanding. The studies found signal numbers and aspects were only read back
around half of the time;
• Pressure at either end of the communication, whether time or work-load affected the
likelihood of read back;
• Familiarity between the parties to the communication meant that personal identification,
job and location were rarely stated, particularly so for follow up calls.
Many of these items may be regarded as ‘cultural’ aspects. Nevertheless, they need to be considered
and dealt with in the training process.

Assessment
Rail Safety Worker competence management regimes should include suitable and relevant systems to
gather, assess, record and disseminate information on personnel and organisation performance with
respect to safety critical communications. This process should gather the necessary material to
adequately assess the performance of the personnel in the communications they undertake.
Additionally, the process should include trainer performance assessments. The trainers’ performance is
the keystone to every person they train and how they subsequently perform their roles.
Assessment systems should include feedback processes to provide for the outcome of assessments to
be made available for review by respective line managers and the personnel who have been assessed, in
order to drive an improvement in learning and communication culture. The emphasis of the assessment
system should be on assisting personnel to make improvement in their communication practices.
Suitable support should be made available to both rail workers and line managers to help provide the
means for performance improvement.
As well as refresher training, RTO’s should consider having assessments conducted periodically. RTO’s
should utilise a risk based approach to determine the period between assessments, which may vary
depending on the type of communications the individual is carrying out. It is suggested that this should
not exceed 24 months as a maximum to perhaps as frequently as 3 months for personnel considered to
be in ‘high risk’ safety critical functions. The frequency of refresher training may have significant impact
on this time scale.
Reviews of communication performance may also be considered following any reports of transgressions
from standard protocols or as a result of audits of communication practices identifying shortcomings in
the practices.

Active Listening
Daily there are many conversations between personnel face to face, over the telephone and possibly
over a radio communications system. Often however the person being the recipient of the
communication message does not listen as well as they could or sometimes should. People are prone to
distraction by other things in the environment, such as the computer screen, other conversations or
activity in the vicinity or something else.
Active listening is a communication technique that can be used to improve all person’s skills at listening
to communications being directed to them. It requires that the listener fully concentrate, understand,
respond and then remember what is being said. By learning active listening skills, personnel involved in

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the safety critical communication processes will become better listeners and actually hear what the
other party to the communication is saying — not just what they think they are saying.
Active listening is essential in ensuring the communication process is completed correctly and ensures
that the person sending the message knows the recipient has received, understood and acted
appropriately to the message being sent.
There are a range of benefits to be achieved from active listening. They are:
• The receiver of the message will take in more information and understand better. This will
ensure that a correct response is given. The communication process will not fail due to
error or misunderstanding;
• Other people will more likely respond with the same level of attentiveness when the
receiver is in turn transmitting a response message;
• Persons communicating will react more positively to the message recipient as they will be
seen to be taking the message seriously and giving it appropriate importance and respect;
• Safety is improved as the effort put into the active listening process will reduce the risk of
any communication errors occurring.

Steps to Better Active Listening

There specific steps that help people become better active listeners. They include the following:
• The first step is to make the conscious effort to listen and concentrate on the person giving
the communication;
• Ensure there are no distractions and manage other tasks so due attention can be given to
the person delivering the communication;
• Then, use your imagination and enter the speaker’s situation. Concentrate and try to
imagine their frame of reference and point of view;
• Observe the speaker’s vocal inflection, enthusiasm or lack of it, and style of delivery. These
are essential components of the message. If speaking face-to-face, pay attention to the
speaker’s facial expressions and other nonverbal cues for more insight into the message;
• Listen without interruption. Note key phrases or use word associations to remember the
speaker’s message content;
• Ask questions to clarify any areas of uncertainty;
• Repeat back the message word for word if a short message, or use paraphrasing if it is a
longer or more general message to confirm the message has been correctly received as
intended;
• Finally, provide acknowledgment, either verbally or by action, that the message has been
understood.

Audits and Threat and Error Management (TEM)

Audits and Inspections
Auditing is a key function for all rail safety critical functions/processes and communications is no
exception. All RTO’s are required to have an auditing schedule developed for their rail activities and this
schedule must be risk based.

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The broader audit process should be varied and with a mix of ‘formal’ and ‘informal’ processes carried
out by the organisations rail safety professionals (where appointed) and members of management at all
levels.
Line management personnel that are close to and/or involved with the communication process could
use such items as checklists or inspection forms designed specifically for the communications function.
Such tools should be more focussed on the day-to-day aspects, and as a minimum, consider looking at
such aspects as:
• Style of language being used (i.e. brief and accurate or rambling);
• Formality of the communications;
• Messages are ‘read-back’;
• Use of phonetics, spoken numbers;
• Minimisation of general conversation;
• Avoidance of interruption and/or distraction;
• Avoidance of unnecessary fill terms such as ‘like’, ‘um’, ‘er’ and y’know; and
• Where documentation is being completed, that the writing is legible and printed.
Routinely, formal auditing of the communication process should be carried out. This should be
performed by suitably experienced and competent personnel who should have knowledge of the
communications processes and management processes.
The audit should challenge the communication processes and test them to ensure they are meeting the
required need. This is a much more detailed and in-depth process and should be developed with regard
to the results of the surveillance and inspection processes described above and also to any incidents
that have occurred.

Threat and Error Management

Threat and Error Management (TEM) is a specialist management model that was developed in the
aviation sector. This model can be used to explore how threats and errors can lead to undesirable
incident outcomes. This approach has gained some favour in the rail sector.
It is not intended here to go into detail on this management model however, RTO’s using this guideline
may wish to explore the process more fully themselves and its potential value to their organisation.
Further information can also be found in the ONRSR guideline on Rail Resource Management. However,
the principle is briefly described below to give an indication as to its use and practice.
The TEM framework is a model that assists in understanding the operational inter-relationship between
safety and human performance in the constantly evolving operational environment. Communication
and communication systems are an integral part of this process.
TEM framework can assist with an examination of the operational context and the people discharging
operational duties in that context. The framework is descriptive because it captures human and system
performance in the normal operational context, resulting in realistic descriptions.
The TEM framework can be used in several ways. These include:
• As a safety analysis tool, it can focus on a single event, as is the case with accident/incident
analysis or alternatively to understand systemic patterns within a large set of events, as is
the case with operational audits.

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• Helping clarify human performance needs, strengths and vulnerabilities, permitting

superior definition of competencies from a broader safety management perspective.
• Assisting with On-the-Job Training (OJT) requirements, helping the organisation improve
the effectiveness of its training processes, and consequently of its organisational
safeguards.
• Provide training to organisational specialists who are responsible for evaluating operations
as part of accreditation.

Communication Task Aids

The use of ‘task support aids’ can greatly assist with the process of communication. Task support aids
can include, but are not limited to, the use of such processes as;
• text messaging to support verbal messaging when there is ‘noise’ or other issue(s) with the
audibility of the message as appropriate;
• ‘Speech to text’, and vice versa, software systems;
• headsets with noise cancelling capability;
• checklists and forms;
• cue cards;
• standardised terms list etc.
RTO’s may also wish to consider the use of video, particularly with the modern smartphone capabilities
with video telephony.

Recording of Communications
All RTO’s should have processes in place that enable recording of safety critical communications. There
are legal aspects relating to this that must be complied with, however these are limited to specifically
‘Train Safety Recording’. As previously identified safety critical communications can be much more than
only train communications.
RTO’s need to consider several factors in relation to recordings. These include, but are not limited to:
• The type of media to record to;
• Duration of retention, particularly given aspects such as training, audits, incidents etc.;
• Accessibility of the recordings i.e. security and disclosure risks;
• What will be recorded and where i.e. radio only, telephones, Train Control etc.;
• Any ‘non-recorded’ devices that may be considered for use in safety critical
communications;
• Any potential ‘privacy’ concerns and brevity of conversations.
An often-overlooked aspect in relation to any recording media, is the need to ensure that for any
recordings that are desired to be kept for extended periods i.e. years, is the need to ensure that any
specialist items relating to that recording also need to be maintained. This includes such items as the
device to play the recording, or the software to decode the recording. Alternatively, consideration needs
to be given to transcripts or other methods of preservation, noting that transcripts do not accurately
reflect any emotion or other inflection that may be heard in the original recording.

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Safety Critical Communications Equipment

All RTO’s should have in place suitable and sufficient procedures and processes to ensure that
equipment used for Safety Critical Communications is:
• Routinely tested;
• Operated correctly in accordance with the manufacturer’s instructions e.g. environmental
aspects such as temperature/humidity parameters, vibration etc.;
• Adequately maintained (where applicable) in accordance with the manufacturer’s
instructions;
• Where applicable, ensure a full set of backup batteries are available on charge or spare
non-rechargeable batteries are available; and
• Checked and tested for its intended operation at the commencement of each shift.
Note: This may not be reasonably practicable for all items of equipment in all potential locations at
every shift.
Many organisations may have their equipment already managed in accordance with their ‘accredited
Safety Management Systems’ or under their asset management processes. For further information on
this aspect refer the ONRSR Publication – Preparation of an Accredited Rail Safety Management System
Guideline and/or ISO 55000 Asset Management.

Written Safety Critical Communications

Although this guideline is principally for spoken communication, it is often necessary that some form of
written communication is linked to the spoken communication(s). Written communication is a mode of
transmission and record of information between one person to another, such as shift change-over,
Safeworking records, log records and/or Pre-Start Briefings to name a few. The primary benefits of
written documents include:
• Provision of background history;
• Preservation of knowledge and learning;
• Provides legally valid evidence and
• Assists in ensuring consistency of activities and operational processes.
All RTO’s should ensure that they have in place procedures and processes for personnel who are
required to complete such documentation that ensures as a minimum:
• Completion of all required items on the form and items not required are clearly identified –
not simply left ‘blank’;
• Completed using permanent ink;
• Numbers are written in numerals, not words, using for example “12” instead of “twelve”;
• Where an error is made then a single line is drawn through errors, and initial corrections or
compile a new form if an error is made;
• Preferably complete the documents in a printed manner (block letters), not cursive; and
• Where practicable, written records should be typed/electronic format to reduce errors
associated with handwriting.

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Hand-Signals
An important form, and the first form of safety critical communications used in railways, is the ‘hand-
signal’. Although this guideline is primarily focussed on verbal/audible communications systems, the
hand-signal process should not be overlooked.
All RTO’s should have in place clear procedures for the use of hand-signals on their networks and ideally
be standardised. Some basic principles in the use of hand-signal includes the following considerations as
a minimum:
• Hand-signals must be given:
– in a clear and timely manner, and
– so that they will be received and acted upon only by those who are being signalled.
• Persons giving hand-signals must:
– be in or have access to a safe place, and
– be in clear view of those who are being signalled.
• Persons receiving a hand-signal must:
– Clearly acknowledge receipt and understanding of the signal.

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Appendix A Safety Critical Communication Procedure

The following procedure should be adopted and used as a minimum when sending and receiving verbal
Safety Critical Communications. Note however, that it is recommended that this process be used for ALL
communications as standard practice.

Start Communication

Sender Start the communication by stating the intended recipient with Name; Role and
Location (if required) and then identifying self:
• When using Open-Channel Radios (except in an emergency) check the
channel is not in use before starting a transmission.
• Operators of rail mounted vehicles must include the receiver’s vehicle unit
number.
• Communications from a worksite must include the sender’s: Name,
Safeworking competency, Track Access Number (or equivalent identifier if
applicable), and Location.
A short identification may be used, after making an initial positive identification.

Receiver Acknowledge the communication promptly (when safe to do so) by identifying self
and who the communication is from.

Exchange Information

Sender and Receiver Communicate messages using the following protocol:

• Provide key information relevant to the task
• Give accurate, brief and clear messages
• Use standard terms (see App C)
• Use phonetic alphabet (see App D)
• Use spoken numbers (see App E)
• Use 24-hour clock to convey times (see App F)
• Avoid use of slang and jargon
• Finish each communication with ‘Over’ (radio only)
Acknowledge messages using the following protocol:
• Listen to the information being provided
• Ask questions to clarify understanding
Ask questions to ensure all relevant information is gained

Receiver Acknowledge the communication promptly (when safe to do so) by identifying self
and who the communication is from.

Sender • Confirm repeat back accuracy. If there are errors, repeat message.
• Prompt receiver to repeat back key information (if required)

Finish Communication

Sender and Receiver Finish the communication using the following protocol:
• Only conclude the communication when the next step has been agreed
• Obtain contact details, including phone number (if required)
• Complete final communication with ‘Out’ (radio only)

The following example of a Driver calling Train Control via radio to report a fault illustrates how the
procedure works in practice.

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 Safety Critical Communications

Train Control: “Driver of TD number one two three four, this is Control over”.:

Driver: “Control, I would like to report an infrastructure fault. Signal number Charlie Alpha
Mike five one six is defective at the stop position, over”

Train Control: “I repeat Signal number Charlie Alpha Mike five one six is defective at the stop
position. Is that correct, over?”

Driver: “That is correct, over”

Train Control: “Roger Driver. I will report the defect to the fault centre. Thank you, Driver, of one
two three four. Control out.”

Note: If it is not possible for a sender to communicate directly with an intended receiver, other
qualified personnel may relay the content. The content of a communication must be relayed
exactly as it was received.

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Appendix B Emergency Communication Protocol

There is a specific protocol for Emergency communications. Emergency communications must–

• start with “emergency, emergency, emergency”;
• be given priority; and
• be answered immediately.
If there is an emergency message on an Open-Channel Radio, other users of the channel must stop
transmission immediately.
Unless they are answering or aiding the emergency call, workers must not transmit unless they are
certain no interference will result.
If an Emergency button is fitted:
1. Press the emergency button.
2. If there is no immediate answer follow the steps for ‘If an Emergency Button is not fitted’.
3. When the Receiver answers, give your location and the emergency message.
4. Exchange necessary information and directions.

If an Emergency button is not fitted:

1. Say “Emergency, Emergency, Emergency. This is (your identification)”.
2. Give brief details about the emergency.
3. If the radio is Open-Channel, users’ other than the Sender and Receiver must immediately stop
transmission.
4. If there is no immediate answer, pause.
5. Repeat Step 1, and Step 2 if necessary, until you are answered.
6. When a Receiver answers, give your location and the emergency message.
7. Exchange necessary information and directions.

At a minimum, the following information should be provided:

• The person’s name or position;
• Location of the incident;
• What has happened;
• Has the incident affected another track or piece of infrastructure; and
• What assistance is required.

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Appendix C Standard Terms

The standard terms in the table below shall be used to convey the associated meanings:

Term Meaning

Emergency, Emergency, Emergency This is an emergency

Correct Yes. You are right

I read back I am going to repeat all, or part, of your statement exactly as I

received it

I say again I am going to repeat all, or part of my last statement

I spell I am going to use the phonetic alphabet

Loud and clear Your signal is strong, and every word is understood

Message received I clearly received and understand your message

Negative No. Not correct

Out * My transmission is complete

Over * I have finished speaking, I am waiting for a reply

Read back Repeat all, or a specified part, of my message back to me

exactly as you received it
Receiving * I acknowledge your call. Proceed with the message

Roger All your last statement is received and understood

Say again Please repeat your last statement

Speak slower Repeat what you said, speaking more slowly. It is hard to
understand you

Stand by Wait. I will be back soon

*Applies to radio communications ONLY.

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 Safety Critical Communications

Appendix D Phonetic Alphabet

The phonetic alphabet (spoken letter names) in the table below shall be used to –
• identify letters of the alphabet;
• to spell words and locations that are difficult to say, or may be misunderstood;
• if there is interference on the radio or phone;
• when quoting the identify of signals or points

For Letter name Say For Letter name Say

A ALPHA AL-fah N NOVEMBER No-VEM-bah

B BRAVO BRAH-voh O OSCAR OSS-cah

C CHARLIE CHAR-lee P PAPA Pah-PAH

D DELTA DELL-tah Q QUEBEC Keh-BECK

E ECHO ECK-oh R ROMEO ROW-me-oh

F FOXTROT FOKS-trot S SIERRA See-AIR-rah

G GOLF GOLF T TANGO TAN-go

H HOTEL Hoh-TEL U UNIFORM YOU-nee-form

I INDIA IN-dee-ah V VICTOR VIC-tah

J JULIET JEW-lee-ETT W WHISKEY WISS-key

K KILO KEY-loh X X-RAY ECKS-ray

L LIMA LEE-mah Y YANKEE YANG-key

M MIKE MIKE Z ZULU ZOO-loo

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Appendix E Spoken Numbers

Numbers shall be said one at a time.

• Use the spoken numbers in the following table.
• Stress the syllables in capital letters.
• For a decimal point, say “Day See Mal”.

For digit Say

0 ZEE-roh

1 WUN

2 TOO

3 thuh-REE

4 FO-wer

5 FI-yiv

6 SIX

7 SEV-en

8 ATE

9 NINE-uh

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Appendix F The 24-Hour Clock

The 24-hour clock shall be used. There are different ways to pronounce the 24-hour clock. Pronunciation
can vary between rail operators and industries. Generally, however the pronunciations in the table
below are acceptable and shall be used to convey times.

Time 24-hour time Acceptable pronunciations*

12 am 00:00 Zero Zero hundred hours

1 am 01:00 One Zero one hundred hours

2 am 02:00 Two Zero two hundred hours

3 am 03:00 Three Zero three hundred hours

4 am 04:00 Four Zero four hundred hours

5 am 05:00 Five Zero five hundred hours

6 am 06:00 Six Zero six hundred hours

7 am 07:00 Seven Zero seven hundred hours

8 am 08:00 Eight Zero eight hundred hours

9 am 09:00 Nine Zero nine hundred hours

10 am 10:00 Ten Ten hundred hours

11 am 11:00 Eleven Eleven hundred hours

12 pm 12:00 Twelve Twelve hundred hours

1 pm 13:00 Thirteen Thirteen hundred hours

2 pm 14:00 Fourteen Fourteen hundred hours

3 pm 15:00 Fifteen Fifteen hundred hours

4 pm 16:00 Sixteen Sixteen hundred hours

5 pm 17:00 Seventeen Seventeen hundred hours

6 pm 18:00 Eighteen Eighteen hundred hours

7 pm 19:00 Nineteen Nineteen hundred hours

8 pm 20:00 Twenty Twenty hundred hours

9 pm 21:00 Twenty-One Twenty-one hundred hours

10 pm 22:00 Twenty-Two Twenty-two hundred hours

11 pm 23:00 Twenty-Three Twenty-three hundred hours

*Note – some organisations do not put the suffix ‘Hours’ at the end of the pronunciation i.e. instead of
‘Zero three hundred hours’, they simply say ‘Zero three hundred’. In some organisations the use of ‘OH’
instead of ‘Zero’ is permitted.

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ABN 58 105 001 465

For information regarding a product

developed by RISSB, contact:

Rail Industry Safety and Standards Board

Canberra Office
Suite 4, Level 4, Place Offices (East)
Terminal Complex, Canberra Airport
ACT 2609 Australia

Brisbane Office
Level 4, 15 Astor Terrace
Brisbane, QLD, 4000

PO Box 518
Spring Hill, QLD, 4004

T +61 6270 4523

F +61 6270 4516
E [email protected]