Are you sure - miscommunication and SPADs

A study of 250 SPAD incident reports in 2016/17 revealed that 17% of incident reports had at least one causal or contributory verbal communications factor. Verbal communication is the exchange of spoken information and is concerned with how (or if) spoken safety critical information is communicated between staff.

Safe railway operations rely on clear and concise communications for safe performance. Communication skills form an integral part of professional railway operations and must be used in all spoken safety critical communications. You should understand the reasons communications go wrong, when common errors take place and how you can make improvements.

Miscommunications – why do they happen? 

There are several reasons why poor verbal communications can lead to a SPAD. These include:

  • Communicating with the wrong person 
  • The person talking leaves out important details, being vague, wrong or overly complex
  • The person receiving the communication not hearing, mishearing or misunderstanding
  • The Rule Book communication protocols not being followed
  • The communication not taking place or happening too late
  • A problem with the communication method.

Although not leading to a SPAD, RED 48, ‘Clear Communication’, provides a real-life example of how miscommunications can lead to a near miss. 

What can you do?

Spoken safety critical communication is effectively a contract, similar to buying a car, renting a flat, or signing an employment contract.  This means conversations should:  

  • identify the parties involved
  • provide information about the situation
  • agree the actions to be taken
  • confirm the agreement 
  • check that a full understanding has been reached by both parties

In summary, we are using accurate, brief, clear and professional communications to achieve an intended outcome.  The ‘contract’ approach helps to distinguish the delivery and receipt of safety critical messages from day-to-day conversation.

You have a responsibility to maintain and develop your skills and knowledge in the area of verbal communications. The non-technical skills ‘communications’ category outlines four specific skills in relation to communications. By improving in each of these skills, you can help reduce the likelihood of SPADs caused by poor safety critical communications (see below).The four skills are outlined below, questions are provided after each skill description. Ask yourself these questions, evaluate your own capabilities, and think about whether there are areas where you could improve. Be honest with yourself!

1. Listening  

Your ability to actively listen to instructions, making sure you hear what is actually being said. This also includes your ability to focus on listening and managing any distractions, both internal and external. Careful listening also relies on you correctly repeating back instructions to verify what was said and confirming your understanding of the situation and what to do next.

Consider the following factor from a recent SPAD incident: 

The driver thought the shunter had given them permission to pass the signal at danger. They misheard the shunter or misunderstood what they were saying. The driver was experiencing difficulty in setting up the GSM-R radio and was focused on this rather than what the shunter had instructed them to do” – SPAD investigation report. 

Ask yourself:

  • How would you have prioritised the task of listening to the signaller’s instructions? Think back to your previous verbal communications with a signaller or shunter and evaluate how well you listened.

2. Clarity

Your ability to communicate clear and concise instructions, avoiding jargon or local terminology, spelling out words, locations or names that are difficult to pronounce or could be misinterpreted. The protocols from the Rule Book help to improve your clarity here. It is also important to be aware how clearly you're speaking, and how factors like workload and your working environment (for example, noise, weather, etc.) impact on clarity.

Consider the following factor from a recent SPAD incident: 

The investigation team concluded the communication by the driver to the signaller was of poor enough quality to allow a misunderstanding to occur. The driver was vague in their communications meaning the signaller misinterpreted the information” – SPAD investigation report. 

Ask yourself:

  • Why might the driver’s communications have been vague? Think back to your previous safety critical communications and evaluate how clearly you communicated instructions to the relevant parties. 

3. Assertiveness 

Your ability to use assertive language and communication skills when needed. This includes challenging unclear communications or instructions in a professional manner, using the correct tone of voice and language. Assertiveness can also include taking authority when required to (for example, when managing complex work). This can also include not giving in to pressure to take short-cuts or break rules.

Consider the following factor from a recent SPAD incident: 

The driver contacted the signaller to report the SPAD, but the signaller had no indication that one had occurred; the signaller then talks about the movement that had taken place. The driver interrupts saying ‘Can I stop you there, I need to point out that I’ve passed the signal at danger and I’m over the points, so you won’t be able to pull the points’. Signaller- ‘OK, I have nothing on my panel to show you have passed the signal at danger, so I will move you up to the next signal. Is that OK?’. Driver- ‘Are you sure?’ then again states they have passed a signal at danger. Signaller- ‘OK, leave it with me and I will make some enquiries’” – SPAD investigation report. 

Put yourself in the driver’s shoes and ask yourself:

  • Would you have challenged the signaller and been this assertive? Think back to previous verbal communications with a signaller or shunter and evaluate your own assertiveness. 

4. Sharing Information 

The ability to understand what the other person needs from your communication and pass on this information in a timely manner. This can include clearly reporting hazards and operational incidents, and completing any forms or paperwork clearly with the required level of detail.

Consider the following factor from a recent SPAD incident: 

When requesting a shunt move from the signaller, the driver failed to state that they are required to continue towards the north end of the station sidings. The signaller therefore did not clear the necessary signal and the driver passed it at danger” – SPAD investigation report. 

Ask yourself:

  • Think back to your own verbal communications: do any examples spring to mind where you could have shared clearer information?


  • RED 54, ‘Stay Focussed’, shows another example of how miscommunications can go wrong after a SPAD incident. Try to evaluate how well the driver and signaller performed for each of the four communication non-technical skills. 

RSSB’s safety critical communication resources 

To help improve the standard of communications and to enhance communication capabilities, RSSB has produced new safety critical communications training materials. Read through the six training modules which outlines several good practice principles to follow when conducting your safety critical communications. There is also a safety critical communication manual, which provides you with additional information on the skills and concepts.


Safety Critical Communication Manual
Safety Critical Communications – Modules 1 to 6
Haven’t found what you’re looking for?
Get in touch with our Principal Human Factors Specialist for further information.
Philippa Murphy
Tel: 020 3142 5641
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.