Thank you, Luke (Upton), for that kind introduction, and for inviting me to speak here today on behalf of the National Transportation Safety Board.
For those of you who are not familiar with the National Transportation Safety Board, the NTSB is an independent federal agency created by Congress to investigate accidents in all modes of transportation, to find out what caused the accident, and to make recommendations to prevent recurrences. Congress created us to focus on safety, and our primary product is safety recommendations.
Our recommendations may be to regulators, such as to the Federal Railroad Administration; to transportation operators such as the railroads; to suppliers; to the unions; to state or local agencies; or to any other entity that can help accomplish the transportation safety improvements set forth in our recommendations.
But we at the NTSB cannot make the changes, and we cannot require others to make the changes.
Instead, we depend on those to whom we make our recommendations to act favorably on those recommendations. So it is a testament to the thoroughness of our investigations, and to the quality of the analysis performed from those investigations, that more than 80% of our recommendations are responded to favorably.
Every year, the NTSB issues a Most Wanted List of Safety Improvements. It is based upon the accident investigations by which NTSB learns safety lessons, and upon the recommendations that are NTSB’s primary safety product. This year, our Most Wanted List includes “Implement Positive Train Control in 2015.”
We first recommended that the FRA study the feasibility of such technology at least 45 years ago, and PTC was on the NTSB Most Wanted List at its inception in 1990. As most of you know, following the tragic head-on collision between a commuter rail train and a freight train in Chatsworth, California, in 2008 – resulting in 25 deaths and more than 130 injuries – Congress enacted the Rail Safety Improvement Act of 2008 (RSIA). This Act requires the implementation of PTC systems on a wide range of railroads by December 31 of this year.
Since RSIA was enacted in 2008, more people have died in PTC-preventable accidents. Most recently, four died and scores were injured in the Metro-North derailment in the Bronx in December 2013.
So I’m excited that I’ve been asked to speak today on the question of “Where are we now?”
Finally, after 45 years of accident investigations and recommendations, and seven years of lead-time under RSIA, “where we are now” is beyond the question of “whether;” and it is also beyond the question of “when.”
We are now looking at the question of “how.”
Over the next two days you will be hearing from some of the foremost experts in the world on the subject of positive train control. So I will not use my time today to talk about the technical details of “how.” Instead, I want to suggest a way for an industry to work on a complex industry-wide safety issue, such as PTC, that has been indispensable in advancing safety in other modes of transportation: collaboration.
Nearly 20 years ago, the commercial aviation industry began CAST, the Commercial Aviation Safety Team. CAST brings together all of the key industry participants - including the airlines, the manufacturers, the pilots, the air traffic controllers, and the regulator, i.e., everyone who has a "dog in the fight," to work collaboratively.
These participants have been working collaboratively to identify potential safety issues; prioritize those issues - because they are identifying more issues than they have resources to address; develop strategies to address the prioritized issues, and then evaluate whether the strategies are working, and working without producing any unintended consequences.
The result has been a major win-win in that the CAST process resulted in a reduction of the fatal US commercial aviation accident rate by 83 percent in its first ten years; and contrary to conventional wisdom that safety and productivity are mutually exclusive, it also improved productivity at the same time. This amazing accident rate reduction was from a rate that, after declining for decades, had begun to stop declining and had been "stuck on a plateau" for several years.
Collaboration is often difficult, especially when it brings together entities that have differing and sometimes competing interests. So collaboration requires strong leadership, to bring the participants together; and it also requires a catalyst. In aviation, there was strong leadership from both the regulator and from industry. Leadership is so important because the typical first reaction from all of the participants, which is human nature, is, “I’m ok . . . the problem is that all of you need to get your acts together.” Strong leadership helps each and every participant recognize the need for self-improvement.
The catalyst was a flat accident rate, in combination with a projection that the volume of commercial airline travel would double within the next 15 or 20 years. So key industry players did the simple arithmetic and realized that “flat plateau rate times double volume means the public will see twice as many high-visibility accidents.” And in the aviation industry, anyone’s accident is everyone’s accident. The public doesn’t say, “That accident was on Airline X, so I’m ok if I fly on Airline Y.” The more typical public reaction is, “That crash makes me concerned about flying.” That’s what motivated the industry to do something different. That “something different” was collaboration.
The moral of the story is very simple: Everybody who is involved in the problem should be involved in the solution.
Today CAST is still going strong. It has proven to be sustainable because it improved not only safety, but also productivity. As much as we safety people hate to say it, safety improvements are much less likely to be sustainable if they hurt the bottom line. Recently the NTSB has also begun to participate in CAST, to bring to the table our insights from accident investigations.
Is this success transferable to the railroad industry? There are certainly similarities between the industries. For example, they are both complex systems of connected subsystems, all of which must work well together in order for the entire system to work. Another similarity is that the engineers and pilots are “first to arrive at the scene of the crash,” so they have a very strong personal stake in improving safety.
Having said that, however, one size may not fit all, because there are also many differences between the industries. For example, a problem that exists for the railroads that does not exist in aviation is that the majority of deaths in rail transportation result from trespassing. That is why we are holding a forum on railroad trespassing later this month.
Another difference is that railroad transportation has a different - and longer - history of labor-management relations that are often very adversarial. Consequently, bringing labor and management together to work collaboratively to improve safety may be a challenge.
Despite those differences, I would suggest to you that there is much that the rail industry can learn from this aviation industry collaboration success, and much of that successful process is transferable. In fact, we have already seen some collaboration success stories in rail. For example, in August of last year, a group of NTSB staff, led by former NTSB Member Mark Rosekind, visited Amtrak to get a first-hand look at the new ACS 64 locomotive. A representative of the union was in the room, as well as Amtrak management.
The representative said the engineers loved the new locomotives, because they had a voice in the design. They were included in everything from picking the seats in the cab to the layout of the technology. The major commercial aircraft manufacturers enjoy a long history of making safer and more efficient airplanes because they involved the pilots from early in the design process.
That’s collaboration at work. As with the design of a new aircraft, the design of a new locomotive reverberates through decades of future use and maintenance. Both in terms of efficiency and safety, we are hopeful that this collaborative approach will yield its own reward.
I mentioned earlier the PTC-preventable accident that occurred in the Bronx in 2013. But we all know that PTC is just one layer of safety, not a magic bullet for everything that can go wrong.
In that accident, the train entered a 30 mph curve traveling at 82 mph. The engineer, who was suffering the effects of severe fatigue stemming from undiagnosed obstructive sleep apnea, failed to reduce the train’s speed. PTC would have automatically slowed the train.
But in addition to the need for PTC, that accident demonstrated a clear need to address obstructive sleep apnea. We are seeing this problem in all transportation modes because Americans are gaining weight, and there is a strong association of sleep apnea with being overweight. Historically, labor has been reluctant to focus more attention on sleep apnea, because they are concerned that a diagnosis of sleep apnea means losing their jobs.
The good news is that sleep apnea is treatable. Because it is treatable, we are hearing from employers who are paying more attention to it, and are reporting a win-win: not only safety improvements, but productivity improvements as well. When vehicle operators are diagnosed and treated, they are safer because they are less fatigued on the job; their morale is improved because they see that the employer is interested in improving their health and safety; and training costs are reduced because there is less operator turnover. Accordingly, in our Special Investigation Report on this and other Metro-North accidents, we recommended that management and labor work together to solve the safety problem posed by sleep apnea that threatens everybody.
We recommended that Metro North include representatives from all divisions and labor organizations not only to regularly review safety and operational data from all divisions to identify safety issues and trends but also to share the results across divisions.
We also recommended that all railroads and railroad unions collaborate to develop a model national labor agreement that supports effective programs for addressing sleep disorders and other medical conditions among safety-sensitive train operating personnel. Because sleep apnea is treatable, nobody needs to be disqualified just because they have it. The far better result for everyone is to diagnose it and treat it.
The moral, again, is that everybody who is part of the problem should be part of the solution – everybody with a dog in the fight should have a seat at the table.
At this conference you will hear a great deal about the details of PTC implementation. We are down to the brass tacks of how to implement PTC, although we all know that it will not solve every railroad safety issue. The basic reason for PTC is very simple – the rail system is a complex system in which humans can make mistakes, even well-trained and highly accomplished humans, and those mistakes can have very serious consequences. That’s not a criticism, but merely a statement of human reality. Given that reality, PTC will provide a very important safety net when – not if – mistakes occur.
Moreover, we should recognize that Positive Train Control can be a starting point to solve many more issues than just the ones that the RSIA envisions.
For example, it is the backbone of a system that can eventually be expanded to avoid even lower-speed collisions, or to stop train movements on an adjacent track within a certain distance of an accident – rather than just on the accident track.
Just as importantly, as railroads, suppliers, unions, and other parties work together to meet the implementation deadline, I urge you to identify and take advantage of opportunities for collaboration going forward.
Working together we can work better, as has been shown again and again in addressing transportation safety issues.
Regardless of the issue, collaboration can be critical to making progress on many safety advances, not just Positive Train Control, and the progress will be sustainable progress because it can improve not only safety but productivity as well.
Meanwhile, we hope that everyone will work together to do all they can to meet the PTC implementation deadline of December 31, 2015.