Literature Review of Safety

Critical Communication

Methodologies

ERA 2014 01 INTEROP OP

Study on safety related

communications methodology

24 October 2014

K.Dobson, A. Moors

and B. Norris

ITLR-T33769-001

Issue 1

24th October 2014

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Executive Summary

Academic and industry literature on safety critical communications in rail and other industries

has been reviewed to identify the principles and evidence underpinning safety communication

methodologies and to inform the European Railway Agency‟s review of Technical Standards

for Interoperability – Operations (TSI OPE) Appendix C.

Estimates of the number of rail incidents that are related to communication issues vary

between 30% and 90% (based on large scale UK research). However, the number of

communications that take place every day on the railway may also suggest that the rate of

errors in communications may actually be low, or does not result in incidents. Nevertheless,

many industries, including rail, recognise that effective communication is vital to good team

work, efficiency and safety and many initiatives have been developed around structured

communication.

Despite these efforts, research has shown that communication rules in the railways, particularly

requirements for formal communication such as read-back, are not followed. Staff do not

follow the rules for a range of a reasons such as culture of the organisation, peer pressure

and usability of procedures; this suggests that miscommunications are manifestations of other

working problems as well as the structure of communications.

The communication of incorrect or incomplete information, plus the failure to communicate at

all are the most common types of communication errors. A taxonomy of communication

errors and mitigations has been produced as part of this study. Understanding the factors that

influence errors– the conditions that make errors more or less likely – is vital if errors are to be

minimised. These include: the context and frame of reference for the communication

exchange; the communication process itself; the goals or aim of the communication (for

instance, everyday/regular versus emergency communications); the communication language;

individual factors such as risk perception, mental models, age, experience and fatigue and

organisational factors such as culture, hierarchies, training, monitoring and assessment.

The literature review has highlighted certain key elements that need to be considered in the

future of rail standardised communications and three main recommendations are made based

on findings from the study:

a) A standard communications protocol for use by all staff involved in safety critical

operational communication is essential

b) Structured messages are beneficial for some but not all safety critical operational

communication; detailed analysis of those messages required for interoperability

and that will benefit from structure and formal protocols will be needed

c) Written rules and procedures using a communications protocol and/or written

messages only achieve maximum effectiveness if they are supported by a

comprehensive training and competence management system for the staff

involved and if supported by a positive safety culture.

3

Executive Summary 1

Glossary of abbreviations and acronyms 4

1 Introduction 5

2 Aim and objectives 5

3 Method 5

4 Structure of this report 6

5 The role of communication in safety 6

5.1 The relationship between communication and safety in the

railways 7

6 How we communicate and what can go wrong 8

6.1 A model of verbal communication 8

6.2 Error taxonomies 10

6.3 Factors contributing to communication errors 11

7 Strategies for reducing communication errors 15

7.1 Generic error mitigations 15

7.2 Initiatives to standardise communications in other industries 21

7.3 Standardised protocols in rail 23

7.4 Alternatives to verbal communications 25

7.5 Scripted Conversations 25

8 Summary 26

8.1 There is a link between communication and safety 26

8.2 There is a range of mechanisms by which communication can fail 26

8.3 There is a range of factors that shape the safety of

communications 26

8.4 Formal, structured communication is most effective but needs to

be used appropriately 27

9 Key findings based on the literature 27

10 References 28

11 Bibliography 31

Amendment Record 33

Contents Page

4

Glossary of abbreviations and acronyms

Abbreviation Description

ATC Air Traffic Control

ERA European Railway Agency

EU European Union

FAA Federal Aviation Administration (USA)

HSE Health and Safety Executive (UK)

IMO International Maritime Organisation

NTSB National Transportation Safety Board (USA)

NSRMU National Safety Research Management Unit (UK)

ORR Office of Rail Regulation (UK)

RSSB Rail Safety and Standards Board (UK)

SBAR Situation, Background, Assessment, Recommendation

TSI OPE Technical Standards for Interoperability – Operations

TTC Train Traffic Control (Sweden)

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1 Introduction

The European Railway Agency (ERA) is reviewing Appendix C of the Technical Standards for

Interoperability – Operations (TSI OPE) 2012/757/EU. Appendix C contains a structured

methodology and phrases for rail communication, and there is currently varied

implementation of Appendix C across the European Union (EU) member states.

In order to assist ERA in the review of Appendix C, Interfleet have conducted a review of

literature on safety communications to help understand the benefits and challenges of

harmonising safety related communication methodology across the EU railway network.

The literature review has included academic research, international government and industry

reviews, guidance and standards, together with evidence from other safety critical industries

such as aviation, process control and healthcare.

2 Aim and objectives

The aim of the literature review was to review the principles and evidence underpinning safety

critical communication methodologies and inform ERA‟s thinking in the review of TSI OPE

Appendix C. Within this, there were a number of objectives:

To understand the link between communication principles and strategies and the

likelihood and type of human error

To look at incident investigation reports that demonstrate relationships between

communication errors and incident types

To look for evidence of improvements in efficiency, effectiveness and performance

related to communication strategies, including interoperability

To identify recommended safety communication strategies

To identify barriers and enablers to effective communication.

3 Method

Interfleet used a systematic literature review approach to identify appropriate and relevant

research papers that had a focus on the role of communication in safety critical environments.

Numerous electronic databases were reviewed using keyword searches to identify the specific

fields of communication information relevant to the review. In addition to transport, global

searches were conducted across other industries such as aviation, emergency response,

healthcare and defence. Existing literature reviews were found to offer a good overview of the

research that had been undertaken, and were used as important sources of data. Interfleet

focused on mostly primary sources by original researchers and some secondary sources such

as the existing literature reviews were included. A first read of the articles that had been

collected was undertaken to get a sense of general content. Article abstract reviews assisted

decisions as to whether the papers were worthy of further reading or inclusion.

Once the relevant research had been identified, a more structured and critical review of the

content of the selected the articles was completed. These were then divided further into core

principals or research themes for example where there was a focus on the role of

formalization in communication or the correlation of human error. The literature report was

then drafted into these themes weaving together the consistent findings across sources to

present the current state of knowledge around communication methodologies within safety

critical industries.

It should be noted that much of the literature discussed in this report is from the UK; this

reflects the available literature rather than the search strategy. The Rail Safety and Standards

Board (RSSB) in the UK have published a number of large-scale, research studies on

communication and human factors research is particularly active in the UK. Together these

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have provided particularly comprehensive literature on safety critical communication

specifically within the rail industry and this is reflected in the findings of this review.

Constraints

A limit of thirty papers was set on the literature review due to the project resource constraints.

This was slightly exceeded in order to achieve completeness of the review.

4 Structure of this report

This report first introduces evidence around the contribution of communication to incident

causation and provides published estimates of the size of the problem in the rail industry.

In order to understand the mechanisms by which communication can go wrong, the report

then introduces a simple theoretical model of communication. From this, the different types of

communication error are introduced together with the factors that influence error. Strategies

for reducing error are then explored. These include generic approaches then more specific

approaches from rail as well as other industries. The role of formal communication protocols

is explored, together with alternatives. Finally, a summary of the findings and

recommendations is provided.

5 The role of communication in safety

Communication has long been identified as a crucial component of safe working in many

safety critical industries. Transport, defence, process industries, offshore industries and

healthcare have all identified communications as a contributory factor in incident causation,

and each have instigated initiatives, rules and protocols to improve the reliability of safety

communications (see Reason, 1997 and Flin et al. 2008 for examinations of organisation

safety and the role of communication). Examples of high-profile incidents caused, at least in

part, by communication include:

Process Industries

Longford - The Esso Gas Plant Explosion

“A combination of ineffective management

procedures, staffing oversights, communication

problems, inadequate hazard assessment and

training shortfalls combined to result in a major

plant upset with consequential tragic loss of

life.” (Nicol, 2001).

Emergency Services

There was a lack of communication between the

rescue co-ordination and the passenger ship

Scandinavian Star during the fire in 1990. The

fire created dense toxic smoke and much of the

loss of the 156 lives was attributed to carbon

monoxide and hydrogen cyanide poisoning. In

addition to hardware recommendations for

ferries, new initiatives were put in place to revise

the standard marine navigational vocabulary and

led to the publishing of standard marine communication phrases (discussed in Section 7).

7

Aviation

The Tenerife Disaster in 1979 involved a

runway collision of two Boeing 747s during

taxi and take-off procedures in low visibility

conditions caused by fog. 583 people were

killed making it the largest single aviation

disaster at the time. A range of

communication errors were highlighted:

two transmissions occurred at the same

time; air traffic control had no standard

phraseology; there was a misinterpretation by the Captain of the KLM aircraft of the "take-off"

phraseology. The aviation industry has spear-headed work on the effect of working

relationships on communications and a whole programme of work for more effective crew

communications has emerged.

5.1 The relationship between communication and safety in the

railways

Communication has long been identified as critical to safety operations across many

industries, and the railways are no exception.

Communications were first identified as a problem area in the UK railway industry in the late

1990s, following investigations into key accidents and research on communications in

maintenance work (Lowe and Nock, 2007). Initial estimates on the extent of communication-

related safety issues were that as many as 90% of rail incidents may have communication as a

contributory factor (Dickinson, 2008). A large study in the UK in 2004 looked specifically at

the role of communication errors in railway incidents, reviewing nearly 400 Rail Safety and

Standards Board (RSSB) Formal Investigations reports (Shanahan et al., 2007). That review

suggested that the figure was far less – but still substantial - about one third of all incidents on

the UK railways were caused at least in part by miscommunications. Most importantly, it

found that the standards of communication are often not as high as they should be and there

is a failure to adhere to laid down rules and procedures. Similarly, an analysis of

communication transcripts between signallers and persons in charge of possessions conducted

by Gibson (2005) identified that failure to implement communication procedures from the rule

book occurred frequently across a whole range of procedures in the protection of a line.

Shanahan‟s report contends however that it is unclear how much of a problem

communications actually are in the sense of how much they contribute to safety-related

incidents and accidents. In particular, if it is the norm for staff to make communication errors

and to violate communication rules and procedures, then it is to be expected that the majority

of incident investigations will discover such errors and violations. But this does not indicate that

these communications lapses have in any way contributed to causing these incidents. Indeed,

since such incidents are comparatively infrequent and communications errors and violations

appear to be endemic, Shanahan suggests that for most of the time poor communications

performance does not cause incidents or accidents. In a study by the UK rail regulator (Office

of Rail Regulation), Dickinson (2008) has also suggested that with 20,000 train movements a

day in the UK leading to a heavy reliance on telephone and radio systems, the actual number

of incidents caused directly by communication issues is relatively low.

While estimates of actual figures may vary, there is no doubt that communication plays a role

in safety, and more importantly there are improvements to be made in railway communication

standards. Communication is a major part of good team work and can be especially

important in „distributed‟ teams (where people are in geographically remote locations) such as

process plants (where the control room is remote), healthcare referrals (where General

Practitioners never talk to hospital teams) or in the railways where signallers, controllers,

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maintenance crews and drivers may never meet. Good communication is fundamental to

workplace safety and efficiency and it is a key activity in co-ordinating human activity. Gibson

(2002) highlights that efficiency can be compromised from the requirement for active verbal

problem solving during communication, which can be reduced by better planning and

processes.

6 How we communicate and what can go wrong

In order to understand the potential for communication error and the link to incident causation

- and importantly, how to reduce the frequency or impact of these errors - we present a simple

model of verbal communication. The model forms the basis for taxonomies of communication

error and generic strategies for reducing errors that are introduced later.

6.1 A model of verbal communication

Figure 1 illustrates a simple model of communication adapted from a UK Health and Safety

Executive report on nuclear safety (HSE NSRM, 1998). The model explains the steps and

decisions taken by the sender and receiver in any verbal communication. With the steps

broken down, the opportunities for errors and the types of error (or error modes) can be

identified (these are discussed further in Section 6.2). The contributory factors that can

influence the likelihood of a communication error are then discussed in Section 6.3 and

strategies for error reduction in Section 7.1.

9

Figure 1 Simple model of communication (taken from HSE NSRMU, 1998)

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6.2 Error taxonomies

Developed within the field of human reliability, an error taxonomy is simply a classification

scheme of human errors. They are useful as a way of identifying how communication can fail,

to collect data on error frequencies and to ultimately develop solutions to reduce the likelihood

of the error.

There are a number of different classifications in the literature that are similar and useful for

understanding communication error, and two of these are shown in Table 1.

„TRACEr‟ is a human error identification technique for the retrospective and predictive

analysis of cognitive errors (Shorrock & Kirwan, 2002). Developed for the Air Traffic

Control (ATC) environment, it has been adapted for use in the rail environment when

investigating incidents. A major study by RSSB (2006a) used a predictive version of

TRACEr_Lite to examine railway communication errors, and the error categories

identified by that study are captured in Table 1. Further classifications of error modes

and mechanisms grouped according to cognitive domains such as errors in

perception, memory, decision making, actions and violations can be found in the

Shorrock & Kirwan, (2002) paper.

Of the error types identified in Shanahan‟s study (2007) the three most common were:

i) failure to communicate at all ii) communicating incorrect information or iii)

communicating incomplete information. They suggest that failure to communicate at

all is consistent with the aviation sector where "absent" communications is the most

common problem.

TRACEr_Lite (Shorrock and Kirwan,

2002)

Shanahan et al. (2007)

Unclear information transmitted

Unclear information recorded

Information not sought or obtained

Information not transmitted

Information not recorded

Incomplete information transmitted

Incomplete information recorded

Incorrect information transmitted

Incorrect information recorded

No communication

Wrong information

Incomplete

Wrong timing

Unclear

Badly expressed

Misheard

Did not listen

Failure to reach common understanding

Reach common but incorrect understanding

Table 1: Communication error taxonomies

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6.3 Factors contributing to communication errors

Flin et al. (2008) classifies the factors (barriers) influencing effective communication into two

main categories (Table 2):

Internal – those factors attributed to characteristics of the individual

External – factors that can be attributed to the environment

Internal External

Language differences

Culture

Motivation

Expectation

Past experience

Prejudice

Status

Emotions/needs

Hearing ability/deafness

Voice level

Noise

Interference or distraction

Separation in location, time

Lack of visual cues

Table 2 Barriers to communication

Similarly, Gibson's (2007) literature review of safety related communications identifies five key

elements of communication that influence the potential for error:

The communication process of sender-medium-receiver

Breakdowns in the process can occur when operators have difficulty in defining the

important information to be communicated. For example at a shift handover or a pre-

task briefing, the sender may have to be selective as to the information to be

communicated due to time restrictions. Certain communication processes may

therefore be suited to some environments but not to others. Ensuring the correct

process is specified for driver-signaller communications, and for what scenarios, is

therefore crucial, before any format or structure is decided.

The goals of the communication process

Understanding the goals of the communication is vital. This means each party

understands what task the other party is undertaking and the information they need to

carry out that task. Misunderstandings can occur when a sender or receiver has made

assumptions and thinks they have conveyed the right message.

The language used in the communication process

The language used can play a large part in successful communication. If fast and

flexible interaction is required then verbal communication can be rapid, however the

pace is always set by the sender, particularly for emergency situations where pressures

to speak quickly may be significant. Language failures can also occur due to ambiguity

of words and their meaning or redundancy in language and expectations.

The context of communication

The most effective methods of preventing communication failures is to make the

message sender as sensitive to the information required by the receiver as possible, so

that they understand the level of information required for that task context.

Individual factors

Individual factors like stress, fatigue and age can affect the communication process. In

particular the effect of cultural issues on the effectiveness of communication is often

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significant. Some studies show working together as a team can help communication

and combat effects of fatigue.

Some of these internal/individual and external/environmental factors are now discussed

further.

6.3.1 Internal mental models

Mental models describe the way individuals perceive and structure the world around them.

Weyman and Kelly (2000) summarise research on the various mental models of risk

perception and their effects on safety critical communication in the workplace. They quote

Pidgeon et al. (1992) that the success of any communication depends upon:

the characteristics of the sender

the characteristics of the receiver

the message being appropriately matched to the frame of reference of the

audience.

Fischhoff et al. (1997) state that people's mental models of risk have the potential to contain

"critical bugs", which can lead to erroneous conclusions, even amongst those who are

otherwise well informed. The sender tends to make judgments based on their expectation of

the receiver, regarding the amount of information they are required to supply. This process of

information filtering can be a key source of communication failures, where information was

known by the sender but it was not communicated to the receiver so the communication failed.

This is a consistent finding throughout the literature reviewed by Weyman and Kelly. This

filtering process is a natural part in conversational communication as communication would

become very extended if we had to explain every assumption each time we spoke.

6.3.2 Language

Tajima (2004) discusses the link between fatal miscommunication incidents and the English

language communicated in the aviation industry. He states that while voice communication

has a natural appeal, the complexity and flexibility of natural language can cause confusion

and misunderstandings due to ambiguity, unclear reference, intonation peculiarities, implicit

inference, and presupposition. Often, miscommunication in aviation is simply attributed to a

lack of English proficiency if the pilots or controllers are non-native speakers of English. At the

same time, pilots and controllers who have high proficiency in English still use improper

English and fail to communicate, two shortcomings that can lead, and have led, to fatal

results.

6.3.3 Organisational factors

Gibson (1997) states that while the process of communication is important, the importance of

factors such as culture and organisational factors on effective communication should not be

underestimated. Supporting this, a survey of nearly 2500 UK railway staff identified the

perceived influences on the quality of communication, and these included issues such as peer

pressure and the example set by management, rather than the formality of communication

itself (RSSB, 2008).

Lowe and Nock (2007) suggest that to introduce structured communication and then achieve

compliance a multi-level approach is required to engender a massive attitudinal shift across a

diverse workforce. This approach includes:

Initiatives in selection, ensuring individuals have the appropriate competencies

Practical training, that explains why rules are safety critical

Regular briefing on processes and communications management

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On-going assessments, to ensure employees apply the communication protocols

consistently.

They make the important distinction 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 a strategy for

implementation briefing, training and continued assessment.

Dickinson (2008) affirms that what really drives an industry into action is leadership and senior

management commitment. And to do this Lowe and Nock suggest that with effective

communication monitoring figures, the costs of communication errors can be calculated to

help engage senior management and release resources.

The rail regulators also need to be engaged to ensure the industry is adhering to principles

and regulatory requirements. Dickinson (2008) details some tools and techniques that the UK

Office of the Rail Regulator (ORR) are implementing which include:

Preventative inspection activities

Adopting an educational role

Raising awareness

Demanding a higher level of performance

Audits of voice communications

Assess adequacy of communications management systems

Use of a structured approach to analyse communications in incident investigations and

their potential for human errors.

From this monitoring key themes that indicate areas for improvement initiatives can be

identified. The ORR's audit findings include the follow areas that need attention in the UK:

More commitment from management

The promotion of good practice

The need to identify and practice communications used for infrequent situations

(present focus is on communications for normal and regular scenarios). This is

consistent with recommendations from RSSB research on radio communication (RSSB,

1996)

More assessment and monitoring of communications

Establishing voice protocols and setting down what is good practice within the

company‟s competence management system

Communication and radio skills in the context of the safety training courses

Skills in safety audits or key procedures that include an important or significant verbal

communication task

6.3.3.1 Culture

The culture that prevails within an organisation will impact on the way that people interact and

communicate with each other. One of the factors that have been researched in other

industries is the known as "authority gradient" (Yacavone et al., 1992). This was first defined

in aviation when it was noted that pilots and co-pilots may not communicate effectively in

stressful situations if there is a significant difference in their experience, perceived expertise, or

authority. This was one of the factors in the Tenerife incident mentioned in section 5 and has

been linked to a number of aviation, aerospace, and industrial incidents.

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The Authority Gradient is essentially a reflection of the difference in power (control or

influence) between individuals within a team. A large difference in power is referred to as a

„steep‟ Authority Gradient and a small difference as a „shallow‟ one. With a steep gradient

junior team members are used as „units of labour‟, they provide physical labour but are not

expected to contribute their insight or knowledge. This would not matter if the boss or leader

were infallible, all seeing and all knowing. Unfortunately all humans are fallible and as the

workload rises so does the likelihood of task fixation, so „all seeing and all knowing‟ is not

likely either. The main problem with the Authority Gradient is that it inhibits those lower in the

perceived organisational hierarchy from challenging information or asking for clarification –

particularly consequential when they see things going wrong. The reasons for not speaking up

can vary:

They are frightened of the other person.

They are concerned that the other person will lose face if a less senior or

experienced person raises an issue that they have not.

National cultural values mean that they are inhibited from speaking up to people

in authority.

It may be that authority gradients exist between people that have different professional roles

such as drivers/signallers.

6.3.3.2 Training and assessment

Cultural issues outlined above highlight the need for training to address issues such as

hierarchy, particularly in terms of how this affects the likelihood of staff challenging and

clarifying safety critical communication. The survey study mentioned above (Human

Engineeing/RSSB, 2008) also included a meta-analysis of research on safety critical

communication specifically in the railways, and identified key requirements for

communications training. These were:

Specific training in safety critical communications will improve the quality of those

communications. To be effective, training needs to:

o Include the opportunity to practice formalisations, especially for staff that do not

use them on a regular basis

o Include realistic communications equipment and a „real world‟ context

o Provide the opportunity for communicating parties to practise together, in order

to appreciate the needs and expectations of other job roles. This is vital to

avoid assumptions about knowledge in communicating parties.

o Include case studies of incidents where assumptions and lack of attention to

detail have lead to miscommunication.

o Include refresher training to maintain standards.

Shanahan, et al (2007) recommend that more training is given to staff to help them monitor

and assess both their own and others communication performance. As demonstrated in

military command decision making, the aim is to become aware of one's own mental process,

to validate assumptions and detect errors. Andrén et al.'s (2010) recommendations also

include self evaluation and peer review within training or assessments.

In terms of assessments, the study stressed that to be meaningful they should provide feedback

to the individual. A standard for monitoring rail communications was introduced in the UK in

2001 which used five categories of assessment: commencement; structure; speaks

professionally; demonstrates leadership; and concludes communication (Lowe and Nock,

2007). This allows immediate identification of areas needed for development.

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6.3.4 Work environment and equipment

Many authors refer to the influence of equipment, environment, technology, noise and job

aids as influencing the effectiveness of communications (Andrén, 2010; RSSB, 2008; Gibson,

2007). It is to be expected that the quality of the medium that is used to transmit voice

communication, in terms of audibility and interference will affect the likelihood of errors such

as missing or mishearing information. In addition, the usability of job aids such as checklists,

forms, cue cards and training material such as sample communications can greatly improve

the safety of communications. RSSB (2008) in their large scale study on formal

communications recommended a UK national Communication Good Practice Guide for the

railways that would include guidance on the design of job support aids and checklists.

Given the developments in train control systems and the attendant changes in communication

technology, it is important that communication procedures and protocols are aligned with

those developments. Future options for written, digital and web-based communications may

support communication efficiency and accuracy. Research in the UK on future rail

communications (RSSB, 2006b) has specified that requirements for formalisations such as

those in Appendix C, must be compatible with any new communications technology

introduced and they should apply to all types of communications.

7 Strategies for reducing communication errors

Flin et al. (2008) provides four general recommendations for improving communications in

teams:

Explicitness

Timing

Assertiveness

Active listening

A key theme is that effective communication is a skill that can be learned, developed and

improved. She notes that active listening is as important as the spoken communication. This

has implications for the organisational policies; providing practical standardised procedures

that are supported by processes to monitor and manage competence. She concludes that

standard protocols enhance communication between incoming and outgoing shifts, this

addresses the communication problems found in industry where safety critical information is

handed over between teams, for example process industries and healthcare.

This section summarises the reviewed research on strategies for reducing communication

errors. The first section sets out general solutions that are applicable across industries that

stem from the model of communication error and communication error taxonomies set out in

section 6. Subsequent sections then describe specific interventions that have been used by

safety critical industries and within rail. Particular focus has been given to the use of standard

formats and phraseology (sections 7.2 and 7.3) as this is most relevant to the objectives of the

literature review.

7.1 Generic error mitigations

Using the communication error taxonomy developed by Shorrock and Kirwan (and shown in

Table 1), corresponding actions and measures that could be put in place to mitigate the errors

have been generated based on the research reviewed in this report. These are shown in Table

3 below.

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Table 3: Error mitigation strategies identified by the literature

Error Type Possible Error Actions How to mitigate the error

Unclear information

transmitted

• Sender uses ambiguous

language.

• Sender does not

articulate message

clearly.

• Sender uses incorrect

communication process.

• Sender assumes message

will be clear to receiver

(perceptual error).

• Words and phrases should be simple and short.

• Articulation should be clear, deliberate and unhurried.

• Letters combinations should use the phonetic alphabet and numbers should be

pronounced clearly, e.g. Zero for "0", decimal for "."

• Ensure the communication process is appropriate i.e. verbal communications are

good for fast and flexible communications and allow for rapid interaction but not

ideal in emergencies.

• Create a more fully defined and widely applied read back process, and script routing

communications.

• The message should be appropriately matched to the frame of reference of the

receiver.

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Error Type Possible Error Actions How to mitigate the error

Unclear information

recorded

• Receiver does not

understand (recognition

failure).

• Receiver misinterprets the

information.

• Receiver does not request

clarification of

information.

• Receiver does not hear

the information clearly.

• Reduce the requirement for problem solving on the job where possible.

• The language in the communication process must be clear and there should be no

ambiguous words.

• Messages should be formalised, defined and constrained to avoid language failures.

The total vocabulary used should be kept as small as possible.

• Ensure the receiver has sufficient competency to interpret the message clearly and

does not require further training.

• Planning processes should reduce the requirement for verbal problem solving at the

time.

• Create a more fully defined and widely applied read back process.

• Ensure that individual factors between job roles are accounted for e.g. if two job

cultures are viewed as sufficiently different this may preclude effective communication

and team-working.

• Ensure that there are no environmental intrusions in the operating situation such as

noise.

• Ensure the receiver is not overloaded with work or fatigued and has sufficient time to

listen clearly to the information.

Information not

sought or obtained

• Receiver afraid to clarify

ignorance.

• Receiver not aware of the

need to seek information.

• Receiver decides not to

seek information.

• Receiver neglects to

• There should be an open communication culture. Messages should be repeated and

requests for clarification formally allowed.

• Ensure that organisational culture is supportive e.g. challenge strong hierarchies.

• Ensure the communication process between the sender, medium or receiver is

monitored.

• The goals and timeline of the communication process should be clear to all parties.

18

Error Type Possible Error Actions How to mitigate the error

obtain information. • Depending on the context of the error, strict self-discipline and enforcement of the

relevant rules and protocols are required to keep risks to a minimum.

Information not

transmitted

• Sender forgets to send

information (attention

failure).

• Sender thinks message is

not important to transmit.

• Sender neglects to

transmit information.

• Sender chooses not to

transmit information-

violation.

• Minimise interruptions, ensure no audible or visual alerts interrupt the sender.

• General noise in the working environment should not mask the effect of speech.

• The goals and timeline of the communication process should be clear to all parties.

• For emergency situations communication procedures should be more formalised.

• Depending on the context of the error, strict self-discipline and enforcement of the

relevant rules and protocols are required to keep risks to a minimum.

Information not

recorded

• Procedures not easy to

use.

• Receiver distracted or

fatigued.

• Decides does not need

recording.

• Procedures should be easy to use.

• Existing systems must be able to handle high volume of communication demands

and inputs.

• Minimise interruptions, ensure no audible or visual alerts interrupt the sender.

• Ensure the receiver is not overloaded with work or fatigued and has sufficient time to

listen clearly to the information.

• Processes should be clear in stating when information should be recorded.

Incomplete

information

transmitted

• Sender filters information

of message.

• Sender makes incorrect

• The sender should be made more sensitive to the information required by the

receiver.

• The sender should have sufficient knowledge base so that they can adjust their

19

Error Type Possible Error Actions How to mitigate the error

assumption of the

receiver‟s mental model.

• Sender misinterprets

situation.

• Sender message is not

heard entirely.

• Sender time constrained

and rushes transmission.

• Sender neglects to send

complete information-

violation.

judgements and expectations of the receiver, to provide the complete information

they need to supply to the receiver in the correct order.

• Processes should be clear about what information may be filtered and what critical

information needs to be communicated.

• Consider alternatives to verbal communication such as text transmissions to avoid

disrupted and incomplete transmissions.

• Alleviate time restrictions and constraints where possible e.g. at shift changeovers.

• Depending on the context of the error, strict self-discipline and enforcement of the

relevant rules and protocols are required to keep risks to a minimum.

Incomplete

information recorded

• Receiver forgets part of

message (memory lapse).

• Receiver does not register

full message.

• Receiver assumes they

have the complete

information recorded-

perception error.

• Words and phrases should be simple and short.

• Ensure the receiver is not overloaded with work or fatigued and has sufficient time to

listen clearly to the information.

• Messages should be formalised, defined and constrained to avoid language failures.

The total vocabulary used should be kept as small as possible.

• Ensure the receiver has sufficient competency to interpret the message clearly and

does not require further training.

• Create a more fully defined and widely applied read back process.

Incorrect information

transmitted

• Incorrect number/letters

transmitted.

• Sender thinks correct

information has been

sent.

• Letters combinations should use the phonetic alphabet and numbers should be

pronounced clearly, e.g. zero for "0", decimal for "."

• Ensure the sender has sufficient competency to transmit the message clearly and

does not require further training.

• Ensure the sender is not overloaded with work or fatigued and has sufficient time to

20

Error Type Possible Error Actions How to mitigate the error

listen clearly to the information.

• The message should be appropriately matched to the frame of reference of the

receiver.

Incorrect information

recorded

• Receiver not aware the

information received was

incorrect.

• Receiver fails to correct

information.

• Receiver receives correct

information but records it

incorrectly (memory or

input error).

• Employ strategies to avoid erroneous conclusions and support operators mental

model of risk.

• Build in error recovery steps to the system i.e. to detect input errors.

• Employ monitoring processes to determine if a message has been correctly

understood i.e. observation of system state.

21

7.2 Initiatives to standardise communications in other industries

The model of communication shown earlier in Figure 1 and the subsequent error

classifications demonstrate there is plenty of opportunity for people to mishear and

misinterpret verbal communication messages. Shanahan‟s study on rail communication error

identifies four layers of successful communication: technical content; compliance to rules and

procedures; language; context. Formal, structured communication supports all of these.

There are clear differences between the communications that take place in different industries,

for instance, flight control in aviation, collaborative decision making in healthcare, compared

to status updates and permissions in rail, many industries have introduced standard

phraseologies to improve the the format and content of safety critical communications and the

lessons from those industries are of interest.

7.2.1 Single language

In industries where there are different languages spoken a single language is sometimes

chosen as the „first‟ language for the industry, for example English is spoken globally for ATC

and on the flight deck. Another example is „SeaSpeak‟ which is a controlled natural

language based on the English language, designed to facilitate communication between ships

whose captain‟s native tongues differ and was formalised as Standard Marine Communication

Phrases (SMCP) (IMO, 2014).

7.2.2 Standardised Phrases

A good example of the benefit of using a controlled phrase is that it can replace a multitude of

phrases, for example "say again" could replace:

Could not hear what you said, please repeat!

Too much noise, repeat what you said!

I am having difficulty hearing what you are saying! Please repeat what you were trying to

say.

A simplified vocabulary also helps overcome interference over radios or noisy environments as

it becomes easier to recognise.

7.2.3 Standardised format

The Emergency Services use a standard format to enable a joint understanding of risk between

different agencies – a key part of situation awareness when attending an incident. Information

is transmitted using the acronym METHANE to structure the communication (JESIP, 2014):

Major Incident Declared

Exact Location

Type of Incident

Hazards present of suspected

Access – routes that are safe to use

Number, type, severity of casualties

Emergency services present and those required.

22

7.2.4 Standardised protocols in healthcare

There has been a widespread, international adoption across healthcare of a structured

communication protocol know as SBAR (Situation, Background, Assessment,

Recommendation). SBAR promotes quality and safety because it helps individuals

communicate with each other with a shared set of expectations. Healthcare teams use SBAR to

share patient information in a clear, complete, concise and structured format and is promoted

as improving communication efficiency and accuracy (Health Foundation, 2014).

7.2.5 Effectiveness of standardisation in other industries

The study carried out by RSSB in 2008 (RSSB, 2008) reviewed the use of formalisations and

the rule books in other sectors such as London Underground, aviation, ambulance, fire,

maritime, military, nuclear and police and in non-UK rail. The study found:

Aviation – While the standard of communications vary they are generally good with

strict scripts to follow for critical movements such as push back. Flight crews and Air

Traffic Controllers (ATCs) have to pass communications proficiency assessments early

in their career and have refresher training and assessments. There are less outside

distractions for pilots than there are for train drivers. The level of education,

communications training, monitoring, assessment and feedback in the airline industry,

specifically among flight crew and ATCs, sets it apart from the rail industry.

Police – The formality and quality of communications varies but is generally considered

to be too informal.

Ambulance Service – 90% of their communications are conducted via text messages

which have reportedly vastly decreased the likelihood of errors or misunderstandings

occurring.

The Fire Service – A good communications culture which uses mentoring of young staff

by experienced staff to improve their communications; some services don‟t have a

communications manual or rule book as communication protocols are so well

established.

Military – Personnel are highly disciplined in terms of communications procedures and

very high levels of assessment and training are evident.

Rail applications (non-UK and non-mainline):

o London Underground – There are more stringently applied requirements than

mainline rail e.g. Track Access Controllers (TACs) have particularly high

standards of communications and will refuse track access if not satisfied. These

strict requirements have been necessitated by the numbers of staff without

English as a first language.

o USA rail – there are financial incentives for compliance with communications

procedures.

o Canadian rail – communications are highly monitored and there are 3 yearly

qualification refresher trainings required.

o Irish rail – largely based on those in the UK.

23

7.3 Standardised protocols in rail

There are a vast number of safety critical tasks and activities that are carried out in railway

operations and nearly all involve verbal communication. In the UK, the RSSB Rule Book

presents over 350 separate occasions when a driver or a signaller are required to contact

each other. There is therefore significant potential for communication errors that have safety

consequences.

The arrangements in place for controlling the risks from communication failure vary across the

rail industry. Everyday procedures require standard words and phrases used across the railway

industry to ensure the safe movement of trains between signallers, drivers, despatch staff at

station and key workers on the track. The UK rail industry Rule Book (GE/RT8000) presents a

format for the beginning of a communication, standard phrases, use of the phonetic alphabet,

lead responsibility and the closure of a communication. Other systems in place across the EU

will be the subject of the interview study and review forming the other part of this study.

7.3.1 Adherence to protocols

Gibson‟s study of UK railway maintenance (2005) found problems with the usability of

procedures; they were difficult to apply consistently in real world scenarios and directly

impacted on human performance. In scenarios where large amounts of safety critical data

such as signal numbers and times were communicated, a significant risk of deviation in

information was created due to inherent features of human language which may not be easily

removed through training.

A study by RSSB in the UK (2006b) which looked at the safety benefits and risks associated

with the use of mobile phones by track workers, collected railway safety critical communication

error data. It identified that existing protocols for safety critical communications are frequently

not adhered to. Findings were that the standard words and phrases set out in the Rule Books

are generally not followed and this problem is widely acknowledged within the industry.

The RSSB study in 2008 looked at options for the further formalisations of communications

within the rail industry. This study found that while there are regulations and rules in the UK

governing the specific format for radio or verbal communications (similar to those outlined in

TSI OPE Appendix 3), such as the requirement to perform read back and the use of the

phonetic alphabet, there is generally very poor compliance with the rules. The key findings

were that:

Standard words and phrases in the UK Rule Book were not adhered to

Formalisations such as „state your message‟ were not used as they were considered

rude or impersonal

There is very widespread use of the phonetic alphabet and single numbers

Read backs were widely used for location and time information but only for other

information if it was considered necessary to avoid a misunderstanding; in particular,

signal numbers and aspects were only read back around half of the time

Time pressure affects the likelihood of read back

Identification, job and location were rarely stated, usually because of the level of

familiarity between the callers, and particularly so for follow up calls.

24

7.3.2 Barriers to the use of standardised communication procedures

As part of the 2008 RSSB study an interview survey of front line staff attitudes found that many

staff said they use the phonetic alphabet and single numbers but many didn‟t fully understand

the concept of „Lead Responsibility‟. All formalisations were seen as important, particularly

„emergency call‟ and „repeat‟ but around 20% thought that there would be no adverse

consequences to themselves of not using formalisations. Nearly half (43%) thought they were

not always necessary and a similar number (45%) thought that as long as there was a clear

understanding reached then formalisation was not required.

Reasons for non-adherence to formalisations have been proposed as (RSSB, 2004 and

2006a):

Staff fail to appreciate how or why formalisations reduce misunderstandings

Familiarity breeds natural language

Staff don‟t want to be seen as impersonal to their colleagues and peers.

7.3.3 Formality versus non-formality in rail communications

A Swedish study published in 2010 takes a pragmatic view of formal safety critical

communications, recognising the inevitability that some informal conversation is likely to take

place in human interactions and examining the effect that this may have on safety (Andrén et.

al., 2010).

Swedish railway has conducted repeated investigations on safety-critical communication that

identified major problems with deficient „conversational discipline‟: a lack of formality; rules

and formal procedures not being heeded; the use of local jargon and the inclusion of non-

task related topics. Investigations had attributed a large number of incidents and accidents to

„bad conversational discipline‟, at least as a contributory cause.

Focusing on Train Traffic Control (TTC) calls, the study identifies a „communication dilemma‟,

where there are competing and opposing constraints:

The accuracy constraint - ensuring a shared and mutual understanding, compensating

for poor communication conditions such as poor audibility and using repetitions if the

parties move out of phase in the conversation.

The efficiency constraint – the need for fast efficient transactions.

There are also social-relational functions, as the calls are often highly repetitive and problem

solving, which means they engender a need for informality. On the negative side, informality

can lead to „compressions‟ or shortcuts which circumvent read-back and can lead to

omissions. It also leads to additions of irrelevant information but these can help to establish

relationships and trust between the parties, helping to establish efficient and responsible

working in the long run, even if they are not part of the task at hand.

Andrén argues that it is hard to avoid any informalisation, as verbal communication has a

conversational logic that is hard to keep out. As with all habituated rule violations, experience

builds over time such that in the vast majority of cases nothing goes wrong, that reinforces the

perception that there is room for informalisation on top of the rule book requirements.

Their analysis suggested that the efficiency constraint had more of an influence over how

conversations performed than the accuracy constraint. Importantly, this leads to missed

opportunities for what they call „repair work‟, the chance to spot and correct errors.

Andrén‟s research suggests that although formality certainly supports the minimisation of error

omissions, it is not practical in time constrained environments such as emergency situations

25

where pressures to speak quickly may be significant. In addition if staff don't appreciate or

understand why formalisations are necessary then levels of adherence will probably be

unsatisfactory.

One of the risks of informalisations is compressing messages (leaving out steps) such as read-

back which is primary cause of omissions. They are common particularly when calls are

repetitious, to improve efficiency or where the formality appears redundant.

Andrén concludes says that rigid adherence to formality is, at some level, not an option, so a

disciplined mixture of formality and informality is suggested. Within this, correct reception

(read back), understanding references and instructions are important, particularly under

complex emergency and perturbed conditions, stressful situations and poor audibility. Gibson

(2005) supports the conclusion about read back, particularly that there is a requirement to

create a more fully defined and widely applied read back process to recover from

communication procedures errors.

7.4 Alternatives to verbal communications

Research on communication safety has suggested that alternatives to verbal communication

such as text transmissions are considered (Gibson, 2005). More specifically, there are

recommendations that the content of a message should determine the method by which it is

transmitted e.g. voice only messages for short simple messages if the job is mobile; text

(emails, text messages) for non-time critical or non-safety critical messages; and use of

decision making aids to reduce cognitive loads (RSSB, 2003).

7.5 Scripted Conversations

Scripted conversations such as Eurostar's "Livret Forumlaire" can add significant value in

conveying typical communication exchanges at training stages (Lowe and Nock, 2007).

Gibson (2005) recommends that planning processes are improved to reduce the requirement

for verbal problem solving at the time through scripting route communications. However Lowe

and Nock (2007) did find that where scripted conversations were used by existing railway staff

they seemed to confuse rather than structure the conversation.

A study in 2007 reviewed the use of scripted communications in hand-signalling operations

(RSSB, 2007). In many cases it was observed that job aids in general are more useful for

inexperienced hand-signallers and for activities undertaken on rare occasions. The sample of

users ultimately preferred a job aid that incorporated a simple flow of activities with

communications prompts, as it was suggested that providing too much text/script to use was

less useful than providing an aide-mémoire. The Swedish study on Train Traffic Control (TTC)

calls also proposed a similar recommendation that forms or checklists are used as visual

reminders to help repair/correct omissions and retain formality when time constraints allow.

Prescribed sequences are suggested as methods to maintain core formality (Anders et al,

2010).

7.5.1 Sterile Cockpit

In 1974 an Eastern Airways flight headed for Charlotte, North Carolina was descending

towards the runway in foggy conditions. From analysis of the cockpit voice recorder, the

National Transportation Safety Board (NTSB) accident report (Airdisaster.com, 2014) describes

how from a few seconds after completion of the in-flight checklist and for several minutes the

flight crew discuss non-operational topics. These topics stop for communications with the

tower, but continue throughout the descent. The Captain‟s last words were „now all we got to

do is find the airport‟, just 3 seconds before impact. The NTSB concluded that conducting

26

such non-essential chatter can distract pilots from their flying duties during the critical phases

of flight, such as taxiing, take off and initial climb. Their recommendations included that the

USA Federal Aviation Administration (FAA) establish rules and educate pilots to focus

exclusively on flying tasks while operating at low altitudes. As a result, the FAA published the

Sterile Cockpit Rule in 1981. This prohibits crew members from performing non essential

duties or other activities – including talking at critical phases of flight. This helps to reduce

distraction and maintain situation awareness. It is a good example of how organisational

processes and procedures can support good communications. It should be noted that any

changes to organisational procedures and processes should be assessed for unintended

consequences. For example, an unintended impact of the sterile cockpit rule may have been

to worsen the communication barrier between the flight deck and flight attendants

(Airlinesafety, 2005).

8 Summary

This section summarises the key points identified by the literature review.

8.1 There is a link between communication and safety

The literature review aimed to investigate the link between communication, safety and

efficiency. Lessons from major incidents in many safety critical industries, including rail, have

identified that communication is often implicated in incident causation. It is accepted that

effective communication is vital to good team work, efficiency and safety.

It is difficult to put absolute figures on how many rail incidents are caused by communication,

as causation is nearly always multi-factorial. Estimates of the number of rail incidents that are

related to communication issues vary between 30% and 90%. However the number of

communications that take place every day on the railway may also suggest that the rate of

errors in communications may actually be low, or does not result in incidents.

8.2 There is a range of mechanisms by which communication can fail

Large scale studies of incidents have identified three main failures in communication:

failure to communicate at all

the communication of incorrect information

the communication of incomplete information.

A number of taxonomies of error types have been developed and are presented in this review.

They include making erroneous conclusions, information filtering and perceptual errors of the

other party‟s needs or mental model. Understanding these error mechanisms is important if

we are then to identify the factors that influence and mitigate the errors. A generic list of errors

and mitigations has been produced as part of this study and can be used in identifying and

evaluating solutions.

8.3 There is a range of factors that shape the safety of

communications

Understanding the influencing factors – the conditions that make errors more or less likely – is

vital if errors are to be minimised. The research has shown the following factors to be

important:

a. The context and frame of reference for the communication exchange

27

b. The communication process itself

c. The goals or aim of the communication (for instance, everyday/regular versus

emergency communications)

d. The communication language (the actual words and phrases that are used)

e. Individual factors such as risk perception, mental models, age, experience and

fatigue

f. Organisational factors such as culture, hierarchies, training, monitoring and

assessment

The last point is particularly important. Investigations into rail communication have shown that

communication rules, particularly requirements for formal communication such as read-back,

are not followed. The reasons for not following rules have been identified socio-technical

issues such as the safety culture of the organisation, peer pressure and the usability of

procedures. This suggests that miscommunications can be manifestations of the working

environment, and not just related to the specific structure of communications.

8.4 Formal, structured communication is most effective but needs to

be used appropriately

Shanahan (2007) identifies four layers of successful communication: the technical content;

compliance to rules and procedures; the language used; and the context. Formal, structured

communication supports all of these. Formal communication certainly 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. The research

reviewed supports the view that messages should be formalised, defined and constrained to

avoid language failures and that the total vocabulary used should be kept as small as

possible. However, the limitations for formal communication are:

i. It may not practical in time constrained environments such as emergency situations

where pressures to speak quickly may be significant

ii. Staff often do not appreciate or understand why formalisations are necessary

iii. Humans naturally revert to familiar/informal styles of communication as it is easy and

more natural, and in order to develop and maintain personal working relationships

A balance is therefore needed between formality and informality. Formal, standard phrases

and structure should be used for specific high risk scenarios and related communications, with

less formal unstructured communication for routine situation communications. Both types of

situation will however require basic communication protocols to be followed.

9 Key findings based on the literature

The literature review has highlighted certain key issues which need to be considered for the

standardisation of safety related operational communication. These will be supplemented and

developed following the other stages of the study.

i. A standard communications protocol for use by all staff involved in safety critical

operational communication is essential

28

ii. Structured messages are beneficial for some but not all safety critical operational

communication; detailed analysis of those messages required for interoperability and that

will benefit from structure and formal protocols will be needed

iii. Written rules and procedures using a communications protocol and/or written messages

only achieve maximum effectiveness if they are supported by a comprehensive training

and competence management system for the staff involved and if supported by a positive

safety culture.

Additional detailed findings are as follows:

iv. The use of a read-back check is one of the most important components of structured

communication in terms of error reduction

v. Technology that supports verbal communication, such as text messaging, is a valuable

tool in error avoidance but should be compatible with existing and new rail technology

vi. The usability of communication protocols must be reviewed

vii. Communication protocols need to be supported and reinforced by regular briefings,

refresher training and awareness raising

viii. Training should include practical sessions

ix. Standards for communications monitoring and ongoing assessments are required to

support the use of communication protocols and communication proficiency

x. Formal/structured communication should be used only where it is appropriate to the

conditions or context, and work is needed to identify the specific requirements for

interoperability

xi. Standardised communication support in terms of checklists, cue cards and visual aids can

help, together with communications good practice guides

xii. Individuals vary in their communication styles and abilities and there will be individual

differences in the ability to practise and maintain formal communications. Therefore

ongoing training is important

xiii. Organisational safety culture and senior management leadership is very important in

maintaining communications standards

xiv. Rail regulators have a role in ensuring the industry is adhering to communication

principles and protocols.

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Amendment Record

Issue Description Distribution Date

1 First Draft Issue ERA 24/10/14

34

For more information please contact:

Originator :

……………………………………………………. Date: 17/10/14

Kate Dobson

Human Factors Specialist

+1 (604) 638 1392 x52484

dobson.k@interfleetinc.com

Checked By :

……………………………………………………. Date: 24/10/14

Beverley Norris

Senior Human Factors Consultant

+44 (0) 7817 977894

norris.b@interfleet.co.uk