Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the Annual Congress of the National Safety Council
Chicago, Illinois, October 27, 1997
Thank you, Jerry, for inviting me to be here today to share some of my thoughts on transportation safety with this most impressive audience. First of all, let me acknowledge that Transportation Secretary Rodney Slater was originally scheduled to speak to you this morning and has had to cancel his appearance to deal with the looming Amtrak strike, which if it occurs will have significant national implications. I have worked with Rodney Slater for years, even before he became Secretary, and know how disappointed he is not to be here because of the priority he places on safety, and because of his respect for this organization, and I am pleased to be here in his place.
We have worked to improve safety with the National Safety Council for more than 25 years. It has been a very productive partnership:
• We worked together to bring about the age-21 drinking laws. That has saved 16,000 young lives already.
• We cooperatively started the national Operation Lifesaver railroad/highway grade crossing safety program. Crashes and fatalities have been cut in half.
• We have also worked together on child passenger safety, recreational boating safety, reducing drinking and driving, and most recently our call to action to address the air bag problem.
Your President, Jerry Scannell, is a true safety advocate and a long-time friend of the Safety Board. We greatly value his guidance and advice.
I understand that in the audience there are safety directors from domestic and overseas industries involved in manufacturing, construction, transportation, and insurance services; leaders of corporations and labor unions, representatives of federal, state, and local governments; researchers from leading universities; and others interested in worker safety.
All told, there are some 4,000 of you here. You came to this Congress because you care about safety and I compliment you for extending the effort to gather information that will make your companies safer places for your employees.
As you may know, the National Transportation Safety Board is the nation's independent crash investigation agency, with authority to investigate aviation, marine, highway, and railroad crashes, and pipeline and hazardous materials incidents. Our mission is to learn exactly what happened in these crashes and why they occurred, to determine causes and contributing factors. We are mandated to make those findings public, and, most important, to issue safety recommendations aimed at eliminating future crashes, deaths and injuries.
The Safety Board's concept of transportation safety has long since gone beyond the criterion of mere crash statistics. The Safety Board has found through years of investigation experience that crashes are rarely the result of one event or factor, but rather the consequence of a sequence or combination of factors. These factors can range from mechanical failures to environmental conditions to human errors to organizational failings.
The safer transportation carriers have more effectively committed themselves to controlling the risks that may arise from each and every one of these factors. The possibility that these factors can affect safety must be anticipated and safeguards must be systematically developed and implemented. All other things being equal, the better this is done, the safer the carrier will be.
I want to speak to you today about an issue that I think can have a major impact on employee safety. That issue is commonly referred to as "corporate culture." Corporate culture can be defined as the beliefs held by workers and managers in the organization about the way operations ought to be. Or more plainly put "the way things are done around here." An employee’s perception of how the company views safety can have a profound effect on their actions and ultimately on the success or failure of a company. Certainly, organizational cultures should be committed to promoting safety as a major element of their strategic plans.
"Corporate culture" has influenced safety since the dawn of the industrial age. I'd like to describe 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 to adequately 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? Did no one at the company consider the ramifications should lifeboats be needed for all occupants?
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.
The Safety Board is the eyes and ears of the American people at crash sites. We are a national archive - funded by the taxpayer - of what not to do, to provide lessons so that the same mistakes are not made over and over again. As the federal government's only multi-modal crash investigation agency, we have worked with industries and regulators covering the entire spectrum of our nation's massive transportation network. We have had the opportunity to examine the corporate cultures of our largest transportation suppliers, and many of our smallest.
As our knowledge and understanding of the role of corporate culture have improved, our investigations have evolved to encompass more than just management. It takes the full cooperation and dedication of every level in an organization to produce an atmosphere where safety is given pre-eminent status in a corporation's strategic planning. But, safety and crash prevention are everyone’s concerns and responsibilities:
• Government is responsible for setting clear regulatory guidelines and standards, and for consistent enforcement of those regulations;
• Management is responsible for ensuring the compliance with those standards, while accommodating variations in individual experience, knowledge, and skills; and
• The operator is responsible for using the knowledge, skill and experience to do the job in the safest way.
Let’s focus on management’s role for a minute. Does the absence of crashes necessarily indicate the presence of safety? Management must develop, nurture and maintain a healthy and safe corporate culture.
Unlike some causal factors, it is not easy to identify corporate culture problems in the early days after a crash. For instance, it can be apparent soon after a train derailment that perhaps a broken rail initiated the crash, but it takes additional information and analysis to conclude that the derailment was caused by management’s decision to postpone replacement of the defective rail.
Or, after a ship grounds on a shoal, investigators learn that there was confusion among the officers on the bridge about the ship's position, but only later is it learned that the confusion is due to management’s neglect to provide training for the deck officers on the computerized navigation system.
Similarly, after a truck drifts into oncoming traffic, we might soon learn that the driver fell asleep at the wheel. But only later do we deduce that management had imposed incentives on drivers to continue on duty rather than rest.
As a matter of good investigative practice, it is never assumed that any operator's actions occurred in isolation. Each driver, engineer, pipeline operator or ship's officer performs the job in an environment of policies, procedures, operating limitations and operating latitudes.
One flag for recognizing potentially unsafe corporate cultures is the discovery of management philosophy and/or practices that are antagonistic or indifferent toward their employees in safety sensitive jobs. Another flag is if an organization's practices vary from the accepted standards found in the industry.
When I look at the crashes the NTSB has investigated since I have been Chairman, their root causes go beyond a mere lack of planning or poor personnel decisions. Each of them were set up by one or more of the following characteristics:
• The belief in an infallible technology.
• The lack of appreciation for the role of the human in a highly technical system.
• The lack of an avenue for divergent opinions.
• The arrogance of management that believed in its inherent superiority to government regulations and sound operating practices.
• The tradeoff between revenue and safety, to the detriment of safety.
• The establishment of an organizational culture that discouraged communication, divergent opinion, and an appreciation for the importance of safety.
In the last 15 years, much has been written, learned, and communicated about the role of corporate culture on transportation safety. Transportation companies and governments around the world have come to recognize and understand better how operator errors, irrespective of their immediate causes, are often influenced by management conduct and attitudes.
Any accident-causing factors we can eliminate can have profound benefits on your company and even on society as a whole. According to the U.S. Department of Transportation, motor vehicle crashes alone, on and off the job, cost employers $53 billion in 1992. To reduce this toll, management has the responsibility to create and foster a climate that encourages safe operations. How many of you require your employees to wear their seat belts when driving on company business? What countermeasures have you implemented to ensure that your employees are not driving when they are drowsy, or not working when fatigued? What policy does your company have against alcohol and drug use? These are simple requirements that will cost nothing to implement but will save your company money.
It takes leadership to operate a safe company and to establish a corporate culture that makes safety a priority. You need to institute the proper policies, train your workers to comply with them, enforce violations of the policies, and ensure that management up and down the line adheres to the policies and serve as role models.
I am proud of my agency’s leadership in bringing the concept of corporate culture to the forefront of safety assurance, and congratulate all of you for your commitment to placing safety into a prominent role in your corporate cultures. The practice of good corporate culture is not just good for safety, it is good for business.
Thank you for inviting me here today, and may the remainder of this year be safe for us all.