Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
Remarks at
Norfolk-Southern Safety Expo and Awards
Norfolk, VA March 9, 2011


Thank you for inviting me to be here this morning. I have to tell you from the minute that I walked into hotel yesterday and saw all of the Norfolk Southern employees congregated in the lobby, to visiting Lambert's Point yesterday afternoon with Ray Jones, Dan Welch and Jeff Yates for a tour of the export coal operation, to walking on stage this morning, I'm struck by the pride that I see on the faces of everyone here. You have a management team that's proud of the accomplishments of their workforce and employees who are proud of the work that they do and the company that they work for.

I could see it at the Expo last night: employees in NS hats, shirts and jackets with their spouses and kids who were excited to be a part of the NS family. And frankly there is a lot to be proud of. Today we are going to hear about the 2010 Hammond award nominees railroaders that showcase how individuals contribute to the excellence of the whole organization.

I have heard for the last 20 years about NS winning the Harriman Award, but this is how it is done - by producing not just one person worthy of the Hammond award, but scores of them, representing every division on the property. I was told that your CEO, Wick Moorman, was recently named Railroader of the Year by Railway Age Magazine. When I asked him last night why he was selected for the award, he demurred and said it was really NS's award, not his. Even when pressed, he remained tight-lipped about his leadership contributions, but he did not hesitate to open up about the NS team's accomplishments. He was clearly very proud of your industry-leading work in the areas of safety, public-private partnerships and new technology.

I think Wick was on the mark with his assessment. The company's success flows back to individuals and the choices that they make choices made by people on the frontlines and by people in the boardroom. Each of you at NS has a role in creating an organization that's greater than the sum of its parts. It's about people. And that is one of two things I'd like to talk to you about this morning. The NTSB has identified two issues in our accident investigations that I think this group needs to hear about: safety culture and combating distractions. Parts of my message may be unpopular, but before you dismiss them, I'd like you to think about the role that you can play in each one.

It goes back to the people, like Monty "Monk" Wilkerson. In the program, I read about how Monk spreads the safety message to all of his coworkers by walking the walk, not just talking the talk. But safety isn't one person's responsibility. Yesterday I saw stenciled on a railroad shed: think safe, work safe, home safe. And at the end of the day, are those just words or slogans printed on a poster or does the company "walk the walk"?

Let me talk to you about an organization WMATA or Metro - which wasn't walking the walk. In June of 2009, WMATA had a collision near the Ft. Totten station that resulted in 9 fatalities. The NTSB ultimately determined that their train control system failed to detect the presence of a train and authorized the following train to enter the occupied block that resulted in the collision. But what we found when we dug a little deeper was that Metro wasn't minding the store. Contributing to the accident was an anemic safety culture flowing from the top down.

Let me tell you why we concluded that. The Metro Board of Directors was focused more on schedules and budgets than safety. They didn't follow up on outside audits or investigations where safety concerns were cited. And in fact, safety wasn't even part of their mission statement. In short, they didn't measure safety or keep track of it. We know if something is important to the top of the organization, it will flow to the bottom of the organization.

So what specific warning signs did they have? Lots of them they just weren't paying attention! For example, during rush hour trains were supposed to be operated in automatic mode to improve efficiency, but the operator of the struck train was operating in manual mode. Our investigators found that he had previously been disciplined when the train he was operating (in automatic mode) overran a station. Well, instead of addressing the failure of the automatic system, they disciplined the employee for the overrun. So the employee, rather than risking another disciplinary action, chose to operate in manual mode so he could ensure that the train hit the right marks in each station. So the punitive approach actually resulted in greater non-compliance and less efficiency during rush hour.

But specific to the cause of the accident, over 4 years before the crash, there were a couple of close calls on WMATA. Two trains almost collided in a different location due to a train control system failure similar to what we saw in Ft. Totten. So they had an opportunity to learn from that event and prevent the next one.

That lesson was totally lost because one side of the company wasn't talking to the other side. The engineering department designed a test to detect the failure, but the maintenance department didn't implement it. If the work crew that had been changing the bonds in the area had used the shunt test the engineers had developed years before, they would have detected the oscillation that showed an empty block, even when it was occupied in the days leading up to the crash.

But was that Metro's only opportunity to identify a spurious signal? Nope, they had an operations center that detected system anomalies alarms that went off when empty blocks that showed occupied and occupied blocks that showed empty. But the operations center had hundreds of alarms going off every day to the point that they became desensitized and didn't pay attention to any of the alarms going off.

Things at Metro have changed a lot since Ft. Totten they had to. But building a culture of trust and respect doesn't happen overnight. There is no question that building a strong safety culture takes time. Management and labor have to be willing to overcome the legacy of distrust and build a new bridge of communication, trust and respect.

The Safety Expo last night and the awards celebration today demonstrate management's commitment and their investment in nurturing a positive safety culture. And this is going to be critical because, as the demographics show, we will continue to see seasoned railroaders retire and new employees come into the railroad industry.

And that leads me to my next topic distractions. At the Safety Board we are seeing distractions cause accidents in all modes of transportation. I am sure you all remember hearing about Northwest Airlines flight 188 that overflew its destination because the pilots were distracted by using laptop computers in the flight deck. But we have investigated accidents going back almost ten years where railroaders were using cell phones or texting that contributed to crashes.

I know you are all familiar with the Metrolink collision with the UP freight train where the Metrolink engineer missed a red signal because he was texting and the result was the loss of 25 lives, including his, for that distraction of a few seconds. Although Metrolink, the commuter rail operation, had a policy that prohibited the use of cell phones while operating a train, this particular engineer habitually violated that policy.

His phone records for the previous week showed traffic of about 100 text messages per day every day about half of which were while he was on duty. On the day of this accident, while he was on duty, he made four outgoing phone calls and he sent or received 41 text messages, including one 22 seconds before the collision. Although he had been counseled by management twice on his improper cell phone use (including one time when it was his conductor who let management know about the engineer's excessive cell phone use) the inappropriate behavior continued. And on that day, the Metrolink engineer wasn't the only one violating policy. Records showed that one of the crewmembers on the UP train was also using his cellphone and texting before the crash.

So even with company policies and Federal Railroad Administration (FRA) rules, we still see continued violations lapses that can lead to accidents and in this case killed 25 people. Following the accident, Metrolink installed cameras in the cabs of their locomotives and the Safety Board recommended to the FRA that it require the installation of inward facing cameras to monitor the activities of engineers and crew members while on duty.

The Chatsworth accident investigation was a watershed moment for the Safety Board and for the rail industry. There is no doubt that the explosive growth of cell phones, Blackberries, iPads and other devices have made it easier for us to communicate with family and friends, surf the internet or watch our favorite shows. So I ask you: how do you address this at NS, on your division or in your yard, shop or locomotive cab?

To close, I want to share with you something I heard last night when I was walking the Expo floor. I had an opportunity to talk with some employees about what they do and I asked them, "What's your safety message?" And one of my favorite responses was something Mike Sakelick of the Pittsburgh division told me. He said his message was really simple the three T's and it's what he's told his kids, whether they're driving a car, buying a house, getting married or having kids. The three T's are Think Things Through.

You don't have to be a Hammond award winner or Railroader of the Year to improve safety. It is the simple things that each of you do or don't do each and every day. Like re-lining a switch at the end of a long work day or not taking a personal phone call while you are on duty. It's about thinking things through each and every time. It's not complicated but it can be hard.

Thank you for your commitment to safety and congratulations to all those that are being honored today.