Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A. P. Hersman
National Transportation Safety Board
"Walking the Walk of Railroad Safety"
American Railway Engineering and Maintenance-of-Way Association
Annual Conference and Exposition
Chicago, Illinois - September 17, 2012
(As Prepared for Delivery)


Good morning, AREMA. And, good morning, to two outstanding NTSB rail investigators from the Chicago area who are here: Cy Gura and Tim DePaepe. Cy and Tim, and the other NTSB investigators, do all the hard work investigating accidents like Miriam, Nevada; Goodwell, Oklahoma; Columbus, Ohio; and Ellicott City, Maryland. I thank them for what they do.

And, thank you all for what you do to keep America on the move, and just as important, for your contributions to the strong safety record of our nation's railroads.

When your predecessor organizations were founded more than 100 years ago, they came together to share best practices to make things safer, to make things better. Today, with your manuals, your training seminars, your webinars, and more, you are continuing their vision.

Yet, as my fellow Hokie, incoming President Jim Carter knows, there is still more work to be done.

Railroad safety flows back to individuals and the choices that they make - choices made every day by people on the front lines and by leaders like you, here at AREMA, as you work to create an organization that's greater than the sum of its parts.

Chuck [Emely] told me this is a very safety minded group of professionals. I know you are focused on a lot of specific technical issues here this week. But this morning, I am going to ask you to step back for a 30,000-foot view of safety and ask you to see the big picture.

And I'll ask you, "What is next for safety?"

I would suggest safety is all about leadership - whether you're running a committee or running a road gang.

I see many folks from Norfolk Southern here today. Last year, I was privileged to join NS employees at their annual Safety Expo and Awards.

On a tour of the NS facilities, I saw stenciled on a railroad shed: "Think safe, Work safe, Home safe."

What about your organization? Do you have slogans painted on walls or printed on posters? Slogans and sayings are "the talk," but does your organization and its employees - at all levels - "walk the walk?"

Let me highlight three organizations that had tragic results of not walking the walk.

First, the Washington Metropolitan Area Transit Authority, or WMATA. In June 2009, two Metrorail trains collided, killing nine people and injuring dozens more. Our investigation determined the collision's cause was the failure of the train control system to detect the presence of a train. The system authorized a train to enter a section of track occupied by another train.

When we dug deeper, we found that the transit authority wasn't minding the store. In our probable cause, we cited the lack of a safety culture - from the top down.

The WMATA Board of Directors had not followed up on outside audits or investigations where safety concerns were cited. Safety wasn't even part of their mission statement.

In short, they didn't track safety, didn't measure it and didn't communicate its importance.

Were there warning signs?

Absolutely.

For example, during rush hour, trains were to be operated in automatic mode to improve efficiency, but the operator of the struck train was operating in manual mode.

Why?

Our investigators found that he had been disciplined when the train he was operating (in automatic mode) overran a platform.

Instead of addressing the failure of the automatic system, they disciplined the employee. Then, rather than risk another disciplinary action, the employee operated in manual mode to ensure the train hit the right marks in each station.

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

And, more than four years before the crash, there were a couple of close calls. Two trains almost collided due to a train-control-system failure similar to what we saw in June 2009. So, WMATA had an opportunity to learn from that earlier event.

Yet, that lesson was totally lost. One side wasn't talking to the other. The engineering department designed a test to detect the failure, but the maintenance department didn't implement it.

If the crew had used the three-shunt test the engineers developed years before, they would have detected the failure.

And, they had an operations center that detected system anomalies, but they had hundreds of alarms going off every day. It got to where employees were so desensitized they ignored the important alarms, along with the nuisance alarms.

Things at WMATA have changed a lot. They had to.

You can fix track and alarms, but building a culture of trust and respect doesn't happen overnight. It takes time. Management must be committed and employees must be willing - and able - to overcome the legacy of distrust and build new bridges of cooperation and communication.

Here's another accident that shows the tragic result of a weak safety culture. And, in this case, just as in the previous example, things are much different today than they were on the day of the accident.

I'm sure we have CN employees here today. Let me recognize CN for its actions because they did not wait for the NTSB's safety recommendations. They moved swiftly to implement new procedures for handling weather bulletins, improving communication and train consist accuracy - exactly what was needed.

Here's what led to the changes:

On June 19, 2009, an eastbound CN ethanol train derailed at a highway/rail-grade crossing in Cherry Valley, Illinois. The ethanol release and resulting fire killed one person in a car waiting at the crossing and injured seven more with 600 homes evacuated and nearly $8 million in damages.

Our investigation determined the probable cause was the washout, discovered an hour before the train's arrival, and CN's inadequate emergency communication procedures that prevented timely notification.

This accident - like too many others - highlights how missteps at multiple points, within multiple organizations, can result in catastrophe.

In this derailment, the missteps started with the railroad and highway department not addressing the cause of wash-outs of the track and continued with failing to repost the emergency contact information at the crossing as well as not issuing a weather alert that would have provided notice to the train crew of a potential flooding or washout condition.

No one person or single action along the way was solely responsible.

It is complex. And, yes, the work you do is complicated, which is why a commitment to safety and a strong safety culture is so important.

The Cherry Valley accident could be a case study for all modes of transportation about why actively managing safety is so important. You can have safety procedures - and you can have employees designated to perform safety functions - but unless you ensure those procedures are followed and employees are communicating effectively, accidents will not be prevented.

Yes, when a company has a strong safety culture it manages and values safety just as it manages and values other vital business functions.

Here's one last before-and-after story. And, this one clearly has a "positive" ending.

Four years ago this month, a Metrolink train collided head-on with a UP train near Chatsworth, California. The force of the collision caused the Metrolink locomotive to telescope into the lead passenger coach by about 52 feet.

The cause: the Metrolink engineer's failure to observe and appropriately respond to a red signal. Why? He was distracted. He was texting. The catastrophic result: The loss of 25 lives, including the engineer's, for that single text.

It was not for a lack of a policy. Metrolink prohibited cell-phone use while operating a train. But this engineer routinely violated that policy. His phone records for the previous week showed about 100 text messages per day every day - about half while he was on duty.

Management had counseled him twice on his improper cell-phone use. The behavior continued. On the day of the collision, the Metrolink engineer wasn't the only one violating policy. Records showed that one of the UP train crew-members was also using his cell phone and texting before the crash.

But safety is more than policies, rules and efficiency testing.

Sometimes, safety requires redundancy.

For decades, the NTSB has investigated rail collisions all around the country that could have been prevented by technology - technology like positive train control.

Last night, Mike [Franke] reminded me that we met on a hi-rail vehicle on a cold, snowy day in Michigan almost eight years ago. I was visiting the Incremental Train Control System project.

We are so concerned about preventing collisions that Positive Train Control has been on our Most Wanted List of transportation safety improvements since 1990.

And, since then, many of you, like Mike, have been involved in PTC pilots or test projects dating back decades.

But it was Metrolink's accident that ignited a national debate about mandating PTC.

With PTC, there are many who say it can't be done that it is too costly or it is too difficult.

Well, last week, I went to Keller Yard to see Metrolink's PTC system. I was able to see their progress because of their investment in safety and the freight and passenger operations working together.

Following the tragedy in Chatsworth, they committed to implementing PTC. They committed that safety is their highest priority.

In 2008, Congress enacted legislation requiring PTC. And, you know about the effort to roll back that mandate; perhaps you agree.

But, I would tell you, from a safety perspective, rolling it back is short-sighted because we keep investigating preventable accidents.

So, going back to my question from the beginning of the speech, "What is next for safety?"

What will your legacy be for the generations of railroaders that follow you?

Members of AREMA, you have many important decisions and issues in front of you: roadway worker protection, track integrity, positive train control and more. But, when you come right down to it, it's all about the decisions you make and what you do each and every day. Safety depends on you and your leadership.

Thank you, all, for inviting me today and for your commitment to safety.