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 in government.

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, Corporate Culture.

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 over safety.

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 be made.

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:

• Information is hidden,
• Messengers are "shot,"
• Responsibilities are shirked,
• Bridging between employees is discouraged,
• Failure is covered up, and
• New ideas are crushed.

On the opposite extreme are what Dr. Westrum calls Generative Organizations where:

• Information is actively sought,
• Messengers are trained,
• Responsibilities are shared,
• Bridging between employees is rewarded,
• Failure causes inquiry, and,
• New Ideas are welcomed.

Ask yourself: 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 :

• The American Train Dispatcher's Association,
• The Brotherhood of Maintenance of Way Employees,
• The Brotherhood of Railway Signalmen,
• The United Transportation Union, and,
• The Brotherhood of Locomotive Engineers.

Five government and state agencies including Transport Canada and the Canadian Transportation Safety Board also attended.

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 on safety.

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?

• Why was the ship allowed to set sail without cheap yet invaluable safety devices, binoculars for the crows nest watch?

• Why did the captain refuse to slow the ship's speed or alter its course, even though he had been warned of the presence of ice fields in his path?

• Why was she allowed to sail with barely enough lifeboats to accommodate half of her occupants? Why were so many of those boats allowed to be lowered with only a fraction of their capacity filled?

• And, finally, why would the ship's management accept as truth the hyperbole that described the ship as "unsinkable?" Why could no scenario be imagined where the watertight compartment design could be considered inadequate?

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 needed?

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 million.

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 might explode.

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 BNSF organization.

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 railroad.

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 transportation.

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.