Vice Chairman Hart

Acting Chairman Christopher A. Hart
National Transportation Safety Board
Operation Lifesaver, Inc.
Albuquerque, NM – May 14, 2014
"Working Together for Continued Improvement"
(Remarks as prepared for delivery)


I want to thank Operation Lifesaver for inviting the National Transportation Safety Board to speak to you today. It's a pleasure to be here with FRA Administrator Joseph Szabo and with you, Joyce (Rose). Thanks to you and your staff for putting together this event.

Since we're here in New Mexico, I also want to take a moment to express my condolences to the friends and family of the bicyclist who was lost at a Santa Fe grade crossing last month. We know that nothing we do or say here can make up for that loss – we can only continue our work to make such tragedies less common.

For those of you who don't know the National Transportation Safety Board: The NTSB investigates accidents, determines the probable cause of those accidents, and makes recommendations to prevent recurrences. Our primary product is recommendations, and our focus – like yours – is safety. We are not a regulator and we cannot require anyone to do what we recommend. So it is a testament to the thoroughness of our investigators and analysts that 80% of our recommendations are responded to favorably.

Since 1975 alone, yearly fatalities due to grade crossings have decreased from more than 900 a year to about 250. You can rightly lay claim to much of that decrease. While we at NTSB can issue recommendations to trucking companies, railroads, their federal regulators, and even state law enforcement (among others,) when it comes to grade-crossing and rail-trespass accidents, your work at the grass roots is key.

Your campaign "See Tracks? Think Train!" tells the average driver or pedestrian much of what he or she needs to know – then you go from there to educate them further. Your training programs for the driving public, for law enforcement, for professional drivers, and for first responders are helping to continue to push down injuries and fatalities.

Movies and other mass media sometimes use trains as symbols, or even glamorize the literal dangers they present. We all remember the scene in "Stand By Me" in which kids decide to walk across a trestle bridge, and end up with a train bearing down on them. Of course, they narrowly escape. In other movies, trucks or cars try to beat the train at a grade crossing.

I understand that some years back, Levis made an ad featuring a model walking lazily down some railroad tracks on a hot day. When a train rushes towards her, she slowly strips out of her jeans and places them on the tracks, to turn them into cut-offs.

Working with members of Congress and the national Parent-Teacher Organization, you persuaded Levis to pull the ad.

Everybody here knows that there's nothing nostalgic or glamorous about a life lost in a railroad trespass or grade crossing accident. The question is what to do about it.

I know what you're still doing about it, Joyce –you've written to Lexus about their "Temptation" commercial, where a driver pulls through a grade crossing before the gate is fully up. I understand Lexus has replied, saying it is taking steps to edit the commercial. You're working to get people out of their own little world, where trains are some sort of emotional symbol, and helping people connect to the reality. Kudos to you for reaching out to the mass media on this issue.

It's no coincidence that we usually see seat belts buckled in the mass media today, and that must certainly help encourage the general public to buckle their belts. Changing public attitudes towards grade crossings and rail trespass will mean changing the images people see in mass media too.

What we can do at NTSB is investigate that reality when accidents happen, make recommendations, and advocate for our safety recommendations to be adopted.

And the more accidents we investigate, the more we see one reality over and over again: a long chain of events all have to come together for an accident to happen.

There's layer after layer of protection against accidents. If there's hole in one layer, the protection in the next layer may stop the accident from happening. An accident happens because there are holes in layer after layer after layer.

It takes all the holes to line up for the accident to happen. James T. Reason developed this model, widely known as the "Swiss cheese model" of accident causation. Let me illustrate this with an accident that happened in Miriam, Nevada, in June 2011.

A truck-tractor pulling two trailers, went through an active grade crossing and into the side of an Amtrak train, killing the truck driver, the train conductor, and four train passengers. Fifteen train passengers and one crewmember were injured. The train came to a stop without derailing; however, a fire ensued, engulfing two railcars and damaging a third.

The signal was flashing and the gates were down. So what went wrong? The truck driver didn't brake until it was too late. We know from skid marks and other evidence that the driver didn't start his hard braking until the front of the truck was less than 300 feet away from the crossing.

Even so, that should have been enough room to stop. But the truck's brakes were badly maintained. If the brakes on the truck had been properly maintained, the accident would not have happened.

So, those two causes, two holes, had to be there for the truck to hit the train.

But that's only the moment just before the accident. Let's look at the other layers leading up to that moment.

Why didn't the driver brake earlier?

He might have been distracted and fatigued, and by the time he did see the grade crossing signal and gates, it was too late. So a hole developed in that layer of protection.

This driver had a history of serious medical issues, and had lost his last job because he didn't meet the company's physical standards for a truck driver. He also had a history of accidents. So on his application to this trucking company, he listed incomplete and inaccurate information.

He also developed tendonitis while working for this company. Was it a factor? Records show that the driver called 4 orthopedic clinics in the 3 hours prior to the accident, among the 30 calls and texts during his duty shift that day.

And, another driver had left him a voice mail just 2 minutes prior to the accident. We do not know, but the driver might have been trying to retrieve that voicemail.

But there are more holes. For example, if another company thought he was physically unfit to drive, why did this company hire him? The answer is that regulations only required them to look back three years into his driving record. They found only three speeding violations and two seat-belt non-use violations.

But since 1995, this driver's license had been suspended 14 times. He'd also been in accidents in 2006 and 2007. We found holes in the regulations and the resources for companies to make good hiring decisions.

But what about the other hole just before the accident, the bad brakes?

The accident truck had two axles with mismatched and incorrectly sized brake chambers, 11 brake drums worn beyond the specified limits, and problems with the automatic braking system, or ABS. In fact, where ABS wheel speed sensors were missing, the wires leading to them were cut and zip-tied out of the way.

Another layer of protection, the maintenance of the truck. Another hole.

And yet another level of protection failed even after the truck struck the train: protection for the passengers and crew of the Amtrak train. Five out of the six people who lost their lives in this accident were on the Amtrak train, not in the truck.

For them, inadequate occupant protection was the final hole in the layers of protection, the last link in the chain.

These were just a few of the holes we learned about in this accident. We issued 20 recommendations to try to help fill them. Many gained acceptance. I understand that the Federal Railroad Administration is working on more crashworthy railcars, and is working with the Federal Highway Administration on model grade-crossing standards. Others did not gain acceptance, like our recommendations to the Federal Motor Carrier Safety Administration to help gather commercial driver driving and employment history and require its use.

And one more big hole: we also have recommendations to eliminate distraction in transportation. In fact, it's so important to us that, like occupant protection in transportation, we placed this issue on our Most Wanted List of safety issues. Here in New Mexico, they've come one step closer to eliminating distraction: a full texting-while-driving ban, with primary enforcement, was signed in March, and goes into effect July 1.

In Miriam, in 2011, the fate of that truck driver became tragically entwined with the fate of those passengers, because railroads and highways are two systems that connect at every grade-crossing.

A background investigator and a regulator became intertwined with them too. So did a trucking company's maintenance procedures, and somebody who wrote the specifications for the passenger car. The more accidents you analyze, the more you see these connections.

The way to get to better safety is to open up to the bigger world. Everything in that bigger world – people, equipment, and information – has to work together successfully. If they're not working together, the holes develop, and the long chain toward the accident begins.

I've worked at the NTSB, the National Highway Traffic Safety Administration, and the FAA, so I've seen that different modes of transportation can learn lessons from each other. One lesson aviation may offer to other modes of transportation is the Commercial Aviation Safety Team, or CAST.

CAST brings together all of the key commercial aviation industry elements – including the airlines, the manufacturers, the pilots, the air traffic controllers, and the regulator, i.e., everyone who has a "dog in the fight" – to work collaboratively. They identify potential safety issues; prioritize those issues – develop strategies to address the prioritized issues, and then evaluate whether the strategies are working.

The result has been a major win-win. The CAST process resulted in a reduction of the fatal accident rate by more than 80 percent in its first ten years.

The moral of this collaboration success story is very simple: Anyone who is involved in a problem should be involved in developing the solution.

Operation Lifesaver began in a single state, Idaho, in 1972, and helped drive down grade-crossing fatalities by 43% there in one year. In the mid-1970s, when the FRA began keeping national statistics about accidents at crossings, there were from 900 to over 1,100 deaths per year nationwide. By 1982, you had offices across the country, and the fatalities had declined to a little over 600. Today the number stands at about 250 deaths per year – but that number has been about the same for the past 5 years. Even more challenging is the trespasser fatality numbers, which have speadily resisted improvement for many years. The impetus for CAST to begin their collaborative effort was that they, too, were concerned that their fatal accident rate had become stuck on a plateau.

To reduce grade-crossing and trespass accidents to lower levels may take improved cooperation and collaboration from throughout the rail and commercial motor vehicle industries, alongside law enforcement, state and federal regulators, and others.

We need you, at Operation Lifesaver, to continue your good work to patch the holes in the awareness layer on which so much of our work depends.

Thanks for all that you have done to further reduce trespassing and grade crossing accidents, and we look forward to working with you further to continue this worthy endeavor.