Basis for Recommendation
The failure to apply safety critical communications protocols was identified as a factor in the incident. Although the rule book defines the need for a clear understanding, no party has a responsibility for ensuring that protocols are applied by the other and there is no hierarchy in communications between parties. In the Professional Signaller Handbook the lead responsibility is assigned to the signalman, but this is not well understood and not reflected in the rule book. It is also not communicated or trained to train drivers. If the lead responsibility of the signalman is understood by all, then this may assist in reaching a clear understanding.