Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
"Building a Strong Safety Culture"
Remarks at
2011 Air National Guard Executive Safety Summit
Orlando, FL - May 3, 2011


Good morning! Hello from West Virginia!

Before I get started, let me congratulate Col. Slocum for receiving the Air Force Chief of Staff's Individual Safety Award in 2008 that recognized his pivotal work with Air Force Maintenance Resource Management, a program that, as you know, empowers every Airman to speak up in the name of safety.

Congratulations to the Air National Guard, for your strong safety record and for establishing a culture focused on getting everyone home safely every night. There are three reasons why I am honored to join you today.

One, you do important work. Your role as citizen soldiers in the Air National Guard is crucial to our national security. I understand that more than three-fourths of you have been deployed. And many of you multiple times.

I thank you for your selfless service to our country.

Two, I appreciate your contributions in a personal way because I am a proud Air Force brat. As my father progressed up the ranks to Brigadier General, we moved from base to base and country to country. Dad was a fighter pilot with more than 3,500 hours in 25 aircraft types. To this day, I love the sound of jets.

As part of the military family, you know how small the world is. So, you'll find it interesting that one of my father's last postings was as Chief of the Operations and Plans Division, Air Directorate, National Guard Bureau, in Washington, D.C.

Third, your conference team has put together an outstanding program on "Integrity, Service, Excellence An Air National Guard Culture of Safety and Leadership." So let me take that theme of how the military family makes the world smaller, and more connected, and talk about your theme building a culture of safety and leadership. To do that, I will talk about culture by discussing a rail accident and about leadership lessons from a baseball player.

Let's begin with the rail accident. On June 22, 2009, a Washington, DC Metro train crashed into a stationary train. Nine people were killed; scores were transported to local hospitals. Two of those people were Dave and Ann Wherley.

Major General Wherley had been commander of the D.C. Army and Air National Guard and some of you may have worked with him or known him.

As I read his biography, I learned that on the morning of September 11, 2001 when I was working in an office on Capitol Hill and my dad was in the Pentagon Wherley was the officer who scrambled fighters into Washington's skies.

Major General Wherley joined the Army reserves as a second lieutenant in 1969. He logged more than 5,000 hours of flying time. And, he and his wife were about to celebrate their 40th wedding anniversary.

One of the survivors of that same crash was a military chaplain Dave Bottoms who had just finished his first day on the pastoral staff of Walter Reed Army Medical Center. He responded to a young woman trapped in the wreckage who called, "Please don't leave me."

Bottoms stayed and prayed with her. He was the last living passenger to exit the train.

To all the chaplains here today: Thank you for your service and for taking care of the rest of us when we most need it.

Most people know about the investigative work of the NTSB, but few know about our work to help family members of accident victims.

Our Transportation Disaster Assistance Division (or TDA) consists of six talented staff members who provide information and access to services for family members and survivors from accidents in all modes of transportation, by coordinating services provided by the airlines, government agencies, the Red Cross, and others. Our TDA group provided assistance to family and friends of the victims after the Metro accident.

So, it is indeed a small world. Today, I use the accident that took the life of a one of your Major Generals as an example of what can happen when an organization lacks an effective safety culture.

The NTSB determined that the cause of the accident was the failure of the train control system to detect the presence of a train. Essentially, the system authorized a train to enter a section of track that was occupied, which resulted in the collision.

When we dug a little deeper, we found that Metro wasn't minding the store. In our probable cause, we cited Metro's anemic safety culture from the top down. The Metro Board of Directors was focused more on schedules and budgets than safety. They didn't follow up on outside audits or accident investigations where safety concerns were cited.

Safety wasn't even part of their mission statement.

In short, they didn't measure safety or keep track of it.

Were there warning signs? Lots. 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 been disciplined when the train he was operating in automatic mode and overran a station.

Well, instead of addressing the failure of the automatic system, they disciplined the employee for the overrun. Rather than risk another disciplinary action, the employee chose to operate in manual mode so he could ensure that the train hit the right marks in each station.

The punitive approach actually resulted in greater non-compliance and less efficiency during rush hour.

Specific to the accident's cause, over four years before the crash, there were a couple of close calls. Two trains almost collided in a tunnel under the Potomac River due to a train control system failure similar to what we saw in Fort Totten in June 2009. So, Metro had an opportunity to learn from that event and prevent the next one.

Metro engineers investigated the close call, but that lesson was totally lost because one part of the organization wasn't talking to the other. The engineering department designed a test to detect the failure, but the maintenance department didn't implement it.

The day before the accident a work crew at Fort Totten changed out an impedance bond and if they had used the test the engineers developed years before, they would have detected the problem with the signal system and prevented the accident.

Was that Metro's only opportunity to identify a spurious signal? No, they had an operations center that detected system anomalies. But with thousands of alarms going off every day, it got to the point where the crews working in the Ops Center were desensitized and didn't pay attention to the alarms at all. Alarms, ranging from open station exit doors to occupied track that was showing as vacant, were all white noise without priority.

Things at Metro have changed a lot since that accident. They had to. But, building a culture of trust and respect doesn't happen overnight. Building a strong safety culture takes time. Management and employees have to be willing to overcome the legacy of distrust and build a new bridge of communication, trust, and respect.

What about organizations with a strong safety culture? What are they like?

Simply put, they always know there is more work to be done. An organization that thinks it has a great safety culture, probably doesn't. Here's an analogy from the world of sports. Did any of you see last month's "60 Minutes" segment on Albert Pujols, first baseman for the St. Louis Cardinals? For those of you from the 139th Airlift Wing and the 131st Bomb Wing, I don't have to tell you about number 5's stats.

In ten years, Pujols has never hit below .300, never had fewer than 100 RBIs, and never hit fewer than 30 home runs. He is definitely above average. Yes, number 5 has talent, but he works at it and his work program is no secret. Pujols readily shares what he does, which is this: 1) He focuses on his goal, 2) he works hard, and 3) he makes a point to learn from others.

The point of bringing up Albert Pujols: It takes work to have a ten-year batting average of .330. And, for any organization, particularly a large and diverse organization like yours, it takes work to have a strong safety culture.

Here are three characteristics of an organization with a great safety culture.

One, it starts at the top. Just like Pujols focuses on a single goal winning the World Series the organization must place top priority on achieving and maintaining a strong safety culture. Commitment and responsibility start at the top. That is why we specifically cited the Metro Board of Directors in our probable cause.

Two, to have a strong safety culture you must work at it, just like number 5. Pujols has a disciplined workout routine in the gym and he takes 15,000 to 20,000 practice swings a year.

Similarly, an organization needs a well-defined and rigorous safety program, such as a safety management system. Safety Management Systems enable organizations to identify and address risks, and have processes that enable them to manage risk. The discipline and standardization of an SMS sets the stage for the safety culture to follow.

Three, in a strong safety culture, there is a commitment, and there are mechanisms, to keep learning. Just as Pujols makes it a point to learn from players he admires, an organization needs to keep learning not just from mistakes, but from others, and from detecting trends. This is why data gathering programs are so important. This is how you detect, and address, any weak links.

In a strong safety culture, there is an atmosphere of trust in which employees are encouraged, even rewarded, for providing essential safety-related information. Most U.S. air carriers have voluntary reporting programs. The two major programs are the Aviation Safety Action Program, or ASAP, and Flight Operational Quality Assurance, or FOQA.

Under ASAP, air carriers encourage employees to voluntarily report critical safety information.

On the other hand, FOQA collects and analyzes digital flight data generated during normal operations. FOQA provides objective information not available through other methods.

U.S. airlines have achieved a host of benefits from FOQA and ASAP information, including changes in training, as well as enhanced operational and maintenance procedures.

That is why in the Metro investigation, we made recommendations regarding establishing voluntary disclosure programs to encourage employees to report unsafe situations without fear of reprisal.

Each one of you can be number 5. Everyone can be a leader. Leadership is not always a title. But, it is always an attitude and determination.

Improving safety and building a safety culture is the accumulation of the simple things that each of you do or don't do every single day. It's about thinking things through each and every time. It's not complicated, but it can be hard.

As I was preparing to speak to you today, I learned more about Major General Wherley. He and his wife are most remembered in the D.C. National Guard community for years of dedication to the National Guard Family Readiness Group and youth outreach programs. In fact, they were returning from a volunteer orientation program for the Wounded Warrior Project at Walter Reed Army Medical Center when they died.

They were celebrated last September when the D.C. National Guard dedicated the new Major General David F. Wherley Jr. and Mrs. Ann (Strine) Wherley Family Readiness Center at the D.C. National Guard Armory.

As we reflect on the contributions each of us make in our organizations and in our communities just like Chaplain Bottoms and Major General Wherley it comes down to this: We are our brother's keeper. Especially when it comes to safety.

As you work to build a culture of safety and leadership, remember Albert Pujols and his approach to success. It's said that the only place where "success" comes before "work" is in the dictionary. To have a safety culture that brings everyone home safely every day, you must constantly work at it.

Thank you all for your service to our nation and for your commitment to safety.

Come home safe!