Good afternoon, and thank you for that kind introduction. Thanks also to APTA for inviting me to speak to you today on behalf of the National Transportation Safety Board. As more and more Americans are choosing public transportation to go to and from work and elsewhere, keeping public transportation safe is becoming increasingly vital, and I want to thank each of you for your tireless efforts to make mass transit as safe as possible for the millions of riders who use it every day.
As you know, the NTSB investigates accidents in transportation, determines their causes, and makes safety recommendations to prevent recurrences. We make these recommendations to anybody who can improve safety. That includes regulators, individual transit agencies, manufacturers, labor unions, and other private companies and agencies at all levels of government.
If that sounds like a broad mandate, it is. And to ensure that we carry out that mandate most effectively, our enabling statute has several provisions that are intended to ensure that our recommendations are based on the facts and evidence that we find in our investigations, rather than politics.
This is why we have a long-standing reputation for going where the facts lead us. Having said that, however, the other side of the coin is that we have no power to require that anybody act on our recommendations.
So it is a testament to our amazing staff of investigators and analysts that more than 80% of the time, recipients of our recommendations act favorably on them. And all of you, as CEOs, will understand when I say that I have a great job because my staff does world-class work, and I get the credit.
But favorable action on 80% of recommendations still leaves a lot of recommendations that are not acted on. So every year, we release our Most Wanted List of safety improvements, our road-map from lessons learned to lives saved.
There are ten items on this year’s Most Wanted List, and today I will discuss four of them, three of which are broad areas of concern that have all appeared on the list many times: End substance impairment in transportation, reduce fatigue-related accidents, and disconnect from deadly distractions.
Of these three broad areas, in public transportation, you have made great progress toward ending substance impairment. Mandatory drug and alcohol testing in the event of an accident, and random testing of safety-critical personnel, have been enormously successful.
But accidents in other modes of transportation have shown us that this is no time for complacency. For example, in 2014, a tractor trailer traveling north on Interstate 35 near Davis, Oklahoma, crossed the median and collided with a southbound medium-size bus transporting 15 members of a college softball team. Tragically, four members of the team died. The remaining occupants of the bus were injured, as were the drivers of both the bus and the truck.
The truck driver had failed to control his vehicle due to his use of synthetic cannabinoids.
We do not yet know how prevalent synthetic drug use is in commercial trucking, but synthetic drug impairment potentially poses a threat anywhere that we rely on traditional testing, including among transit agencies. Even when a substance is identified and added to a testing schedule, a minor tweak to its chemical makeup yields a new substance that is neither illegal, per se, nor on any list of drugs to be tested for.
New approaches in highway transportation have focused on trained drug recognition experts who look for drugged driving behaviors in addition to testing regimes. We must remain alert to the possibility that in the future, synthetic drugs may become a factor in transit safety.
While we must remain vigilant against drug impairment, our accident investigations have demonstrated that fatigue and distraction have played more prominent roles in mass transit accidents in recent years.
Regarding fatigue, there is a basic disconnect because much of public transportation is 24/7, but human beings are not.
For example, at about 2:49 a.m. on March 24, 2014, a Chicago Transit Authority train collided with the bumping post at the end of the center pocket track at O’Hare Station. The lead car rode over the bumping post and went onto the boarding platform and then up an escalator that went up from the platform to provide public access to O’Hare International Airport. Fortunately, no one was using the escalator at the time. But of the 50 people on the train, 34 were taken to the hospital, including the operator.
Our investigators found that the train operator had fallen asleep at the controls. This was the result of the challenges of working shiftwork, circadian factors, and acute sleep loss resulting from her ineffective time management while she was not on duty.
In interviews, she indicated that she often felt drowsy toward the end of midnight shifts. Yet her history of time management outside of work showed that she did not make proper use of her off-duty rest opportunities. She accumulated sleep debt in the three days leading up to the accident, despite having two off-duty periods of 12 hours and 26 hours.
But our investigation also found that the CTA failed to manage the operator’s work schedule to mitigate the risk of fatigue. She was assigned to the extra board, meaning that she could be called upon to work any shift throughout the day. In addition, at the time of the accident, she was working her twelfth straight day.
As a result of this accident we issued a recommendation to the FTA to implement federal hours-of-service rules through the state safety oversight program. Some of your agencies have hours-of-service rules, and some do not. If your agency does not have such rules, along with a comprehensive fatigue management program, please talk to others here who do, and start working on mitigating fatigue. You do not have to wait for the FTA to begin improving your organization’s fatigue policies.
I mention comprehensive fatigue management because hours-of-service rules are necessary but not sufficient. In commercial trucking, for example, hours-of-service rules have been the norm for years. Yet we recently completed investigating an accident that, once again, demonstrated the problem that we saw in the CTA accident: You cannot control what an operator does off-duty.
In 2013, a tractor-trailer slammed into a line of slowed traffic on the New Jersey Turnpike, seriously injuring comedian Tracy Morgan and killing another passenger in the limo van in which he was riding. We found that the truck driver was in compliance with hours-of-service rules. Nevertheless he had been awake 28 straight hours before the crash. He had been awake for 28 hours because on the day and night before picking up the tractor-trailer at his duty station in Wilmington, Delaware, he drove from his home in Georgia.
Thus, the challenge is how to ensure that employees arrive ready to perform their duties safely, and remain ready to perform their duties safely for the duration of their time on duty.
The third of the broad areas from our Most Wanted List that I want to address is distraction, in which we are seeing troubling new trends. More specifically, portable electronic devices are dividing our attention as never before. In transportation, these distractions can be deadly.
For example, in 2008, near Chatsworth, California, a Metrolink train collided head-on with an oncoming Union Pacific freight train. The collision resulted in twenty-five fatalities, including the engineer of the Metrolink train.
The Metrolink engineer did not observe and appropriately respond to a red signal because he was distracted by text messaging. Contributing to the accident was the lack of a positive train control (PTC) system that would have stopped the Metrolink train short of the red signal, thereby preventing the collision.
As many of you know, this accident spurred Congress to require PTC in intercity passenger rail, to stop trains when their human operators do not. When Congress enacted this requirement, we removed PTC from our Most Wanted List. When we saw how slowly PTC implementation was progressing, we put it back on the list. When the statutory deadline was not met, Congress enacted a new deadline, and now PTC remains on our Most Wanted List.
I cannot state strongly enough how important it is to implement this critical backstop.
But while PTC would have prevented the Chatsworth accident, the cause of the accident was the operator’s distraction.
Some of your agencies no doubt have policies and rules in place regarding portable electronic devices. If you do not, once again, please network with your colleagues who do, so that you can address the issue more effectively and efficiently in your own operation.
Addressing substance impairment, fatigue, and distraction is very important, but they are actually only symptoms of a larger problem. The larger problem is the lack of an adequate safety culture. To use Jim Reason’s analogy, addressing the three specific issues is like swatting mosquitoes. A solution that is much more effective and long-lasting is draining the swamp. Tackling the larger problem by creating a more robust safety culture, so that each individual operator takes personal responsibility for not being impaired, fatigued, or distracted – even without specific rules -- is more like draining the swamp.
And I am very excited to have the opportunity to talk about draining the swamp here, with CEOs, because you’re the ones who are in the best position to do it.
How do you create a better safety culture? One answer is the creation of an effective safety management system, or SMS. Experience has shown that an SMS helps create, and in turn is also enabled by, a strong safety culture.
For SMS to work, everybody in an organization has to buy into it. In that regard, experience has also shown that SMS is more accepted by the rank and file, and that the rank and file is more willing to tweak it as needed, if they are involved in helping to create it, as opposed to management creating it and mandating that it be used. When they help create it, it addresses their needs more effectively, and they are more eager to make it work because they have an ownership interest in it. But all of that starts with you.
As CEOs, you have enormous power to determine how successfully safety culture can take root in your organization.
And, it’s a natural fit. Your core business is bringing your customers safely from point A to point B.
And the best way for you to demonstrate that it’s your core business is by being fully engaged in the process of developing and implementing SMS and creating the foundation for a strong safety culture. This means that you can’t simply name a chief safety officer and then wash your hands of safety. You can’t simply hire a consultant to implement an SMS, and consider safety covered. You can’t just buy software that’s supposed to create a safety solution.
To be sure, chief safety officers, consultants, and software tools may all be helpful or even necessary to implement an SMS. But the indispensable player in establishing an effective safety culture is you, the CEO. Without your meaningful engagement, and without your ensuring meaningful engagement by the rank and file, this whole process will quickly turn into large notebooks full of procedures that sit on a shelf, but that are not followed in day-to-day operations.
What is it I am asking you to do? Based on our accident investigation experience, I would like to ask you to consider three things:
The first is that safety is not a priority or a box to check. Safety is a core value.
That’s important, because priorities can be rearranged and ranked, and boxes can be checked and ignored. Safety has to play a role in every decision you make – it’s not one of these competing priorities.
You can set budget considerations against on-time performance metrics. You can set fare increases against either of these things. But you cannot set any of these priorities against safety, because safety is not a priority – it is a core value.
The second thing to consider is that safety is a continuing journey, not a destination. Take the first example that I mentioned earlier, impairment in transportation.
The fact that we have seen a reduction in impairment in transit accidents does not mean that we can take impairment off of our list of concerns. Quite the contrary, every development in safety – for example, the emerging concern about synthetic drugs – must be considered as you move forward. You never arrive at safety. You can only continually improve to make your operation safer.
As they say, “If you think you have an effective safety culture, you probably don’t.” Indeed, our investigation experience has shown that the safer an operation becomes, the more likely it is to face another insidious issue, which is complacency.
That’s why it is so important for you to set the tone. Your tone informs every level of your operations. And setting the tone invites needed engagement from the rank-and-file.
Let’s look at the pillars of an effective SMS: Safety policy, safety risk management, safety assurance, and safety promotion.
Safety policy falls right into the lap of senior management: You define the methods, processes, and organizational structure that you need to continually improve safety. But to do so realistically, you have to engage the rank and file.
Safety assurance means evaluating the effectiveness of your implemented risk management strategies and supporting the identification of new hazards. The rank and file is also crucial to this pillar of SMS because they are the best source of information about what is working well and what is not, and what the hazards are.
Safety promotion includes training and promotion to ensure that every member of your workforce is aware of your safety policies and procedures, and that every employee accepts them as part of a positive safety culture. Again, the promotion will be much more meaningful to the rank and file if they are involved in creating it.
And finally, safety risk management determines the need for changes to risk controls based on risk assessments. Needless to say, one of the best sources of information about how to improve what is not working well is the people who live it and breathe it, up close and personal, every day – your rank and file.
That’s why it is important for you to encourage and empower this feedback from your workers, and ensure them that your reporting system is non-punitive and that, absent criminal or intentional wrongdoing, their reports will not be used against them.
This brings me to the third thing I would like you to consider: Asking the experts.
One of the basic principles of High Reliability Organizations is “Deference to expertise.” Once you have set the tone, you’re primed to reap the input of the experts - those who know the most about your organization’s work because they do it every day.
SMS is a “system” because it depends on the successful interaction of many parts. And like other systems, it depends on feedback to achieve its purpose.
Your middle managers play a critical role in this structure. Your embrace of safety culture must be transferred through middle management, in no uncertain terms, and must include bottom-up non-punitive reporting so that you can, and do, fix the little problems before they become big problems.
In this regard, I would like to comment on some recent developments at Metro-North. Metro-North recently announced that maintenance-of-way employees and mechanics have agreed to join a Confidential Close Call Reporting System, or C3RS. The transportation trades (Train and Engine Crews) had already signed on. Having all of these stakeholders willing to accept a C3RS makes the Metro-North C3RS the first of its kind in commuter rail. So kudos to Metro-North.
Having said that, it is a tragic but not unusual fact that Metro-North arrived at these agreements after a series of five accidents in the span of only one year.
At the NTSB, we often see action in the wake of an accident. We issued many recommendations to Metro-North during this period, and we specifically investigated the role of organizational factors in these accidents.
It is heartening to see Metro North implement this first-of-its-kind C3RS, and we hope to see others of you following suit. All too often, corrective actions are taken only by the agency that had the accident. It would be even more heartening if others of you could learn from, and take actions based upon, what happened at Metro North.
We know, however, that merely having a close-call reporting system is not enough. Now that Metro North has created a close-call reporting system, their challenge is to act upon the information that it provides. A recent investigation into an accident on Washington’s Metropolitan Transit Authority’s Metrorail system shows what can happen when this feedback does not result in safety action.
On January 12, 2015, an electric arc fault trapped hundreds of passengers in a smoke-filled tunnel near the Washington Metrorail’s L’Enfant Plaza station. Eighty-six people were treated on-scene, nine were transported to medical facilities, and tragically, one passenger died.
Our investigators identified many safety issues that led to that event, several of which were related to shortcomings in the safety oversight of the Washington Metropolitan Area Transit Authority, or WMATA. What happened in this case was that safety concerns were known to WMATA management, and even to the Tri-State Oversight Committee, or TOC, which oversaw safety for Metrorail.
Yet the TOC did not have the power to enforce any recommendation or ruling, and was answerable not to one state government, as is the norm; or even two, as is the case for some State Safety Oversight Agencies. Members of the TOC had to answer to two states and the District of Columbia. This safety oversight by three jurisdictions is unique in transit rail.
With no effective safety oversight, WMATA’s managers disregarded needed improvements to its facilities and procedures.
This is why I want to discuss one more item from our Most Wanted List today that is specific to rail transit: Improve Rail Transit Safety Oversight.
Presently, the FTA is in transition from being a funding agency to being an agency that has both funding and safety oversight roles. The FTA has new powers under MAP-21 and the FAST Act to implement transit rail safety oversight.
However, the FTA’s new safety authority works through the states. Historically, we have learned from numerous transit accidents that safety oversight is better under some SSOAs than others. Thus, the FTA is on a learning curve regarding how to exercise its new safety authority, and we are on a learning curve regarding how this new authority can most effectively be implemented to improve safety.
We will continue to examine the way that the Federal Transit Administration is implementing such oversight – not only in Washington, but nationwide.
In closing, safety begins with you but ultimately has to be implemented by everyone. Thus, the more you include everyone in developing and implementing the safety improvement process, and the more they recognize that your goal is not to punish them, but to enhance their ability to do better and more safely what they do every day, the more they will engage with you to make it work better. After all, when all is said and done, their safety is at stake, too, and your tangible commitment to their safe return home every day will go a long way to encouraging them to engage fully.
Experience has also shown that the fuel for safety improvement is information from the front lines about what is working; what is broken, mechanically or organizationally; and about how to fix what is broken. Thus, the more you demonstrate that you value the information they provide regarding what could be improved and how to improve it, as Metro-North has done with their near-miss reporting program, the more eager they will be to provide their expertise.
Set the tone: safety is a core value, not one of several competing priorities or a box to check;
Seek continuous improvement: Safety is a continuing journey, not a destination;
And ask the experts: your employees.
Continually improving safety depends on involving everybody who can make a difference – that is, everybody in your organization.
Thanks again to APTA for inviting me to speak. The fact that you invited me indicates that you are interested in learning from the results of our accident investigation experience; and the fact that you are interested shows your commitment to improving safety.
Now I will be glad to take any questions.