Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the 1997 E. H. Harriman Memorial Awards Luncheon
Washington, DC, May 19, 1997
Good afternoon ladies and gentlemen. It is
an honor for me to address this gathering for the 1996 E. H. Harriman
Memorial Awards and the 1996 Hammond Award. Thank you for your
most gracious welcome.
The National Transportation Safety Board recently
celebrated its 30th anniversary. In those three decades, the Board
has investigated thousands of railroad accidents and incidents,
and, through its recommendation process, has played an important
role in improving railroad safety. We take pride in our part in
bringing about such safety enhancements as event recorders, two-way
end-of-train devices, tank car safety and toxicological testing.
I like to say that the NTSB is the eyes and
ears of the American people at accident sites. Because of the
high profile of the Safety Board, most people are shocked to learn
that we have only 360 employees. At an annual cost of about 15
cents a citizen, I think the Safety Board is one of the best bargains
I have been associated with the Harriman Awards
for most of my tenure on the Board. Any award process has its
detractors, but as long as we remain mindful not to allow a quest
for a particular honor to obscure why we are all here - to make
the railroad industry as safe as possible - we will be fulfilling
our responsibilities to your customers and our bosses, the American
people. The Harriman Award recognizes this type of responsible
leadership in the railroad industry, and that is why I am proud
to be a part of it.
Today I would like to take full advantage of
my situation - I have your attention and the only microphone in
the room - to talk to you about a subject that I feel is very
important to the safety of our nation's transportation systems,
What is Corporate Culture? Let me suggest that
it might be defined as stable characteristics of one company or
organization that distinguishes it from another organization.
Or, put more plainly, "the way things are done around here."
Although the Board might not describe "corporate
culture" per se in its reports, it does investigate, and
always has investigated, how culture may have set the stage for
accidents. We look at management practices, policies and attitudes.
And while we use the term "management" broadly, we understand
that the best management in the world cannot overcome the influences
of a corporate culture that is bent on emphasizing other attributes
How does corporate culture affect safety? To
answer this question, the National Transportation Safety Board
convened a symposium last month that gathered over 600 individuals
from industry, government, and academia to learn about corporate
culture and to identify areas where viable improvements might
On the first day, we heard discussions on the
issues. Among the very interesting insights to the problem was
that of Dr. James Reason, Professor of Psychology at the University
of Manchester, England, who told us:
"A safety culture is not something that springs up ready-made from the organizational equivalent of a near death experience. Rather, it emerges gradually from the persistent and successful application of practical and down-to-earth measures."
Dr. Ron Westrum of Eastern Michigan University very effectively described the importance of corporate management in creating and defining the environment in which all employees operate. He also described three types of organizations he had found represented in American companies. On one extreme were organizations he labeled as Pathological Organizations. Pathological Organizations are those organizations where:
On the opposite extreme are what Dr. Westrum calls Generative Organizations where:
Which organization would you like to work for? Which organization
do you work for?
On the second day of the Corporate Culture Symposium, breakout sessions were held to see how what we had learned could be applied to the individual transportation modes. The railroad session was well represented with participants from most of the major railroads and some regional and short line railroads, and several transit agencies. The Association of American Railroads, the American Short Line Railroad Association, and the Railway Progress Institute were also present. Labor was represented by :
Five government and state agencies including
Transport Canada and the Canadian Transportation Safety Board
During the railroad break out session, the discussion took on a very definite labor/management tone with the overriding theme being "TRUST". Let me share with you the results of these discussions. The break out groups were asked to do several things.
First, they were asked to identify the changes
that would most powerfully improve the safety culture of their
organizations. The group spoke of the need for partnership between
railroad management and railroad labor - a partnership that builds
trust, where management and labor can share vision and values,
and where employees at all levels are not only empowered, but
responsible to do the right thing.
Next, the group was asked to identify the constraints
to the changes they had just discussed. The group found that the
biggest constraints were distrust between labor and management
based on lack of effective communication. Also identified as a
constraint was the long tradition of the railroad industry - the
tradition of "iron men" who could bear any hardship
to build and run the railroad.
Finally, the group talked about another constraint
within the traditional railroad organizational structure - an
organizational structure where responsibility for safety was often
buried under the Operations Group. It was felt that the leader
of the Operations Group often struggles with two conflicting priorities
-- to run trains, and to run trains safely.
Corporate culture has provided either negative
or positive reinforcement on operational safety since the dawn
of the industrial age, I'd like to point out one of the most famous
examples of the negative influences corporate culture can exact
Eighty five years ago, mankind's belief in
the infallibility of its work bore its terrible and inevitable
result. The loss of the RMS TITANIC demonstrated the folly of
management overconfidence in its operation, leading to its failure
adequately to prepare for predictable, if unwelcome, events. But
why would the finest ocean liner the world had ever seen at that
time fall victim to such failures?
Granted, there was a regulatory culture that
allowed these things to happen, but where was the conscience,
or just the common sense, of company management? Just because
the TITANIC was allowed to have so few lifeboats, did no one at
the company consider the ramifications should the lifeboats be
The fact that this calamity occurred on her
maiden voyage I think was the ultimate irony and a monument to
individual arrogance, but at the tragic loss of 1,500 lives. Yes,
it was Captain Smith who refused to reduce his speed, but if investigators
had stopped there, then we would surely have seen a repeat of
that catastrophe. We wouldn't have had the imposition of ice patrols
on the Atlantic, or international requirements for lifeboats to
accommodate an entire ship's complement, for example. The loss
of the TITANIC was a good example that the proximate cause is
not the same as the probable cause; we must dig deeper to get
to the true safety issues.
But, we do not have to go all the way back
to 1912 to find examples of where corporate culture problems set
up events that resulted in an accident. We have an examples from
1994 and 1996 at Cajon Pass in California.
Two accidents which occurred at about the same
place in California bring corporate culture issues closer to home
in that they involved a Class I railroad. At about 5:21 am, on
December 14, 1994, a westbound Santa Fe intermodal train collided
with the rear end of a standing westbound Union Pacific (UP) unit
coal train, near Cajon, California. The two crewmembers from the
Santa Fe train were injured when they jumped from the moving train
before the collision. Six locomotive units and three articulated
container cars were also destroyed. Damage was estimated at $4
The National Transportation Safety Board determined
that the probable cause of this accident was insufficient available
train braking force for the Santa Fe train due to an undetermined
restriction or blockage in the trainline between the third and
fourth articulated cars. The Safety Board also concluded that
had the train been equipped with a two-way, end of train device,
the collision could have been avoided because the engineer could
have initiated an emergency brake application from the end of
the train, bypassing the blockage.
Just over a year later, on February 1, 1996,
a second accident took place in the same area. A Santa Fe freight
train, consisting of four locomotives and 49 cars was traveling
westward, between Barstow and San Bernardino, California when
the train "ran away". The train derailed after descending
the Cajon Pass at a speed of about 60 to 65 mph on a three percent
downgrade. Two crewmen on board the Santa Fe train were killed
in the accident.
Although the train was equipped with a two-way
end of train device, the device was not armed. The engineer and
carman who performed brake tests on the accident train before
it began its descent down the Cajon Pass stated that they tried
to arm the two-way end of train device but were unsuccessful.
If the device is not armed, the two-way end of train device acts
as a one-way end of train device where the engineer still receives
brake pipe air pressure readings, but cannot initiate an emergency
brake application at the rear of train.
Forty-five of the 49 cars derailed. All four
locomotives and the derailed equipment caught fire. Four of the
cars that burned contained hazardous materials. Some product spilled
into the dry river bed of the Cajon River. An evacuation of 1-1/2
mile radius was made involving about 60 people. Interstate 15
was initially closed for over 48 hours immediately after the accident,
and then was closed again two days later due to fear that one
of the hazardous materials tank cars involved in the accident
Santa Fe senior officials had promised the
Safety Board after the first accident that trains coming down
Cajon Pass would be equipped with two-way end of train devices.
When this policy reached the field supervision level, however,
local supervisors interpreted the requirements to mean that trains
could still be dispatched without working end-of-train devices.
Although senior officials thought that all but the shortest trains
traversing Cajon Pass had two way end-of-train device protection,
in reality, a significant number of trains were routinely being
dispatched without this protection. The Safety Board included
the Santa Fe Railroad in its probable cause because of Santa Fe's
failure - as a corporation - to adequately interpret and follow
its own safety policies.
After the second Cajon accident, the corporate
culture of the Santa Fe, now the Burlington Northern Santa Fe,
seemed to dramatically improve. Staff members of the NTSB railroad
division visited California and rode freight trains through Cajon
Pass to observe first hand Santa Fe's latest train handling techniques
and latest policies regarding the use of two-way end of train
devices. In addition, Mr. Don Itzkoff, Deputy Administrator of
the FRA, and Mr. Jim Schultz, FRA Regional Director for Region
7 briefed the Safety Board on the working partnerships that the
FRA and California Public Utilities Commission formed with BNSF
labor and management on the Cajon Subdivision. They described
in detail the positive effects this partnership has had on BNSF's
approach to safety and the Safety Corporate Culture of the entire
Interviews with operating crews in the Cajon
Pass region confirmed the positive results of this partnership.
One locomotive engineer with over twenty years of experience in
this territory told us that for the first time in his career,
he was asked to discuss the techniques he used to bring trains
down the pass safely. Now, he was sharing his knowledge and with
less experienced engineers at partnership meetings and through
a mentoring program.
There seems to be a new appreciation for safety
at BNSF and, today, NO freight train navigates the Cajon Pass
without either a tested, fully operational, two-way end-of-train
device or a helper locomotive.
We are all involved in safety programs designed
to reduce the numbers of railroad related accidents, injuries,
and fatalities. In the past, the railroad industry made many changes
in the way they do business that have resulted in a significant
improvement in the accident rates. Now, however, the low hanging
fruit has, in many cases, already been picked and there are fewer
opportunities for easy fixes that can have a significant impact
on railroad safety.
It is my firm belief that if accident rates
are to continue to fall, changes in corporate culture -- to make
safety a major part of our strategic plans, goals, and objectives
-- is where we need to concentrate. Overcoming the corporate culture
hurdle can certainly lead us to the next great reduction in accidents,
injuries and fatalities.
Our purpose today, however, is not to dwell
on our failures but to celebrate our accomplishments. The Harriman
Award is presented to the Railroads in each operation class that
has the best employee safety record for the preceding year. The
Hammond Award honors an individual railroad employee for extraordinary
efforts in promoting safety and a safe workplace on his or her
Everyone in this room, by your presence here
today, has a stake in railroad safety and can take pride as an
industry in today's award winners. And you don't have to be an
award winner to be proud of the work that is celebrated here.
Because all of you have contributed to the Railroad Industry's
improving safety record. All of you can take pride in the progress
that has been made to date and the progress that will continue
to be made in the future.
The transportation community has come to recognize
that everyone has a responsibility for creating and fostering
a climate that encourages safe operations. The practice of safely
moving passengers and freight on our Nation's railroads is not
just good business, it is a responsibility that everyone in this
room has to their industry, their customers, and the American
public -- a responsibility to provide safe and efficient rail
So let's make sure that all of us in this room
are winners again next year. Let's keep up the good work and make
1997 the safest year for railroad transportation ever.
Thank you for your attention.