Acting Chairman Deborah A.P. Hersman
Good morning. Welcome to the National Transportation Safety Board's forum on Safety Culture. I am Debbie Hersman, and it is my privilege to serve as Acting Chairman of the NTSB. Joining me are my fellow Board members: Christopher Hart, Robert Sumwalt, Mark Rosekind and Earl Weener.
Over the next two days we will hear a lot about safety culture – the challenges in defining and measuring it, the programs and techniques that have been utilized in implementing it, and the successes and failures in trying to sustain it. We will listen to leadership perspectives about what "it" is... the oversight, management and coordination commitments necessary to nurture and grow an organization's safety culture and also the need to ensure a positive safety culture during tumultuous periods.
This is not the first time this issue has been approached. The NTSB's predecessor, the Civil Aeronautics Board, addressed organizational issues during the investigation of a DC-3 accident in 1962 where a company supervisor dispatched an aircraft without a qualified crew in order to complete a post-maintenance test flight. That was over 50 years ago but the role of organizational, corporate, and today - safety culture in transportation accidents has persisted. During the British judicial inquest of a 1987 Herald of Free Enterprise ferry accident, in which 193 passengers and crew perished, Lord Justice Sheen referred to management failures as "the disease of sloppiness." In a report published the following year relating to the Chernobyl nuclear plant disaster, the term Safety Culture was first coined in response to organizational failures identified in that event. After a series of transportation accident investigations which were, in part, attributed to organizational failures, in 1997 the NTSB hosted a Corporate Culture and Transportation Safety symposium, and yet, we continue to see accidents attributed to deficiencies in safety culture – so today we are here to ask the experts have things really changed and what else needs to change?
In the 16 years since our last symposium, there is greater awareness that organizational management is a critical component of safe and successful operations within the transportation system. Today, we see the increased use of tools such as data monitoring programs, voluntary reporting systems, and safety management systems. Technology and improved data collection have revolutionized the insight companies have into their own operations. There are also industry efforts to continually expand knowledge, such as the recent Transportation Research Board hosted Roadway Safety Summit and company-endorsed safety standdowns. There are many dedicated professionals who have been instrumental in bringing about mature thinking on safety culture - some of them sitting in this very room. I would like to take this opportunity to recognize my colleague, Member Robert Sumwalt, for his constant encouragement and steadfast leadership on the subject here at the NTSB. We are fortunate to have him as an excellent mentor in this area.
Today, many organizations embrace the basic premise of safety culture and the use of data to improve the safety of their operations, with knowledge that was previously unimaginable. But saying you have a positive safety culture and living it are two different things. Unfortunately, over the last 16 years, the NTSB has investigated accidents and incidents where a weak, non-existent or misguided organizational culture has contributed to the disaster. This morning – a rail accident, a pipeline accident and an aviation accident will be presented – three different forms of transportation but all had organizational deficiencies which led to tragic consequences. This is not just a U.S. concern – our international colleagues have identified similar issues during their investigations, nor does it discriminate – every single mode suffers equally. On that note, I would like to acknowledge two fellow Board Members joining us here today from the Transportation Safety Board of Canada, Kathy Fox and Joe Hincke.
Through this forum, we hope to be able to provide some guidance to the transportation industry – to operators, regulators, and safety investigators – in identifying the essential pillars of a safety culture. As you will hear in the next two days, though there will be different presentations, definitions and labels, there are nonetheless common characteristics found in successful organizations. If safety is truly a core value, it resonates at all levels and permeates into the practices of every single individual so that they do the right thing, even when nobody is watching… because they believe it is the right thing. And it is about establishing and maintaining an atmosphere where safety is paramount and employees make the right decisions over profits, over time constraints, over obstacles ...without fear of reprisal for doing the right thing.
Developing and maintaining techniques that lead to a good safety culture often takes consensus, training, money, procedural changes and perhaps most important, trust -- implementation will not come without some resistance, and it will not occur overnight, but positive change can prevail. The deliberate steps taken to ensure a good safety culture can help to address risks and trap errors but they cannot insulate an organization completely. Over the decades we have found that even the most conscientious organizations are not immune from accidents, likewise having a good safety record is not synonymous with having a good safety culture.
While we, at the NTSB, often play the role of critic in a post-accident environment, we know that cultivating a positive safety culture within an organization is no simple task. It is far easier to criticize others, than to look inside your own organization and admit shortcomings. Self-evaluation is a valuable process and no organization is immune from discomfort when confronted with its own weaknesses. However, it is only when we identify and expose limitations – that we can mitigate them. Because the world around us is continually changing, an ideal solution yesterday may not be the best approach today. Success requires flexibility and communication within an organization and is dependent on continual evaluation and evolution. A truly outstanding safety culture recognizes that it can always improve. Successful safety cultures value the journey as much as the destination and they recognize that the ultimate target will always outdistance the organization.
In the days ahead, I urge you to learn from each other. What we hear will allow us to develop a framework to better look at our own organizations, at our own cultures, and encourage the use of techniques that can be adapted to any organization. Now, I will turn the podium over to Dr. Loren Groff who, along with Dr. Barry Strauch, has done an outstanding job working together to prepare this forum.