Thank you for inviting me here today.
You know the Safety Board for its high-profile investigations like the crash of TWA flight 800 last year, or the derailment of Amtrak's Sunset Limited in Mobile, Alabama a few years back. Much of our work involves nuts-and-bolts documentation of wreckage and accident scenes, but much of our work also involves delving into more subtle areas of inquiry, sometimes leading us into management suites, or even corporate boardrooms.
What I'd like to discuss with you today is an area that is only recently gaining currency in many corners of our transportation industry, the issue of "Corporate Culture" and its affect on transportation safety.
Although "corporate culture" has provided either negative or positive reinforcement on operational safety since the dawn of the industrial age, I'd like to open this discussion with one of the most famous examples of the negative influences corporate culture can exact on safety.
Eighty five years ago, mankind's belief in the infallibility of its work bore its terrible and inevitable result. The loss of the RMS TITANIC demonstrated the folly of management overconfidence in its operation, leading to its failure adequately to prepare for predictable, if unwelcome, events. But why would the finest ocean liner the world had ever seen at that time fall victim to such failures?
- Why was the ship allowed to set sail without cheap yet invaluable safety devices, binoculars for the crows nest watch?
- Why did the captain refuse to slow the ship's speed or alter its course, even though he had been warned of the presence of ice fields in his path?
- Why was she allowed to sail with barely enough lifeboats to accommodate half of her occupants? Why were so many of those boats allowed to be lowered with only a fraction of their capacity filled?
- And, finally, why would the ship's management accept as truth the hyperbole that described the ship as "unsinkable?" Why could no scenario be imagined where the watertight compartment design could be considered inadequate?
Granted, there was a regulatory culture that allowed these things to happen, but where was the conscience, or just the common sense, of company management? Just because the TITANIC was allowed to have so few lifeboats, did no one at the company consider the ramifications should the lifeboats be needed?
The fact that this calamity occurred on her maiden voyage I think was the ultimate irony and a monument to individual arrogance, but at the tragic loss of 1,500 lives. Yes, it was Captain Smith who refused to reduce his speed, but if investigators had stopped there, then we would surely have seen a repeat of that catastrophe. We wouldn't have had the imposition of ice patrols on the Atlantic, or international requirements for lifeboats to accommodate an entire ship's complement, for example. The loss of the TITANIC was a good example that the proximate cause is not the same as the probable cause; we must dig deeper to get to the true safety issues.
As you may know, the National Transportation Safety Board is the nation's independent accident investigation agency, with authority to investigate aviation, marine, highway, railroad, pipeline and hazardous materials accidents. Our mission is to learn exactly what happened in these accidents and why they occurred, to determine causes and contributing factors. We are mandated to make those findings public, and, most important, to issue safety recommendations aimed at eliminating future accidents, deaths and injuries.
These recommendations are directed to carriers, equipment manufacturers, unions, oversight agencies and professional associations in all modes of transportation that can set standards or otherwise communicate our safety messages to their members. We do all this with a very small staff - 360 people - and a budget of about $40 million. Our yearly budget would fund the Department of Transportation for 9 hours of a single day. At an annual cost of 15 cents per citizen, I think the Safety Board is the best bargain in government.
An accident, which represents a major failure of the operating system in which it occurred, often results from a combination of circumstances. These circumstances can range from mechanical failures to environmental conditions to human errors to organizational failings. Let me paraphrase one of my former colleagues on the Board, Dr. John Lauber, who said that the absence of accidents does not necessarily indicate the presence of safety.
The safer carriers that we see across the transportation modes have more effectively committed themselves to controlling the risks that may arise from each and every one of these factors. The possibility of these factors affecting safety must be anticipated and safeguards must be systematically developed and implemented. All other things being equal, the better this is done, the safer the carrier will be, and the accident statistics will reflect these conditions.
The Safety Board is in a unique position because for 30 years we have been the eyes and ears of the American people at accident sites. We are a national archive - funded by the taxpayer - of what not to do, to provide lessons so that the same mistakes are not made over and over again. As the federal government's only multi-modal accident investigation agency, we have worked with industries and regulators covering the entire spectrum of our nation's massive transportation network. We have had the opportunity to examine the corporate cultures of our largest transportation suppliers, and many of our smallest.
What is corporate culture? Let me suggest that it might be defined as stable characteristics of one company or organization that distinguishes it from another organization. Or, put more plainly, "the way things are done around here."
Although the Board might not describe "corporate culture" per se in its reports, it does investigate, and always has investigated, how culture may have set the stage for accidents. We look at management practices, policies and attitudes. And while we use the term "management" broadly, we understand that the best management in the world cannot overcome the influences of a corporate culture that is bent on emphasizing other attributes over safety.
As our knowledge and understanding of the role of corporate culture has improved, our investigations have evolved to encompass more than just management. It takes the full cooperation and dedication of every level in an organization to produce an atmosphere where safety is given pre-eminent status in a corporation's strategic planning.
As I said, the Board recognizes that accidents are not usually caused by one solitary factor, nor do they occur in a vacuum. Safety and accident prevention is everyone's concern and responsibility:
- Government is responsible for setting guidelines and standards;
- Management is responsible for enhancing the compliance with those standards, while accommodating variations in individual experience, knowledge, and skills; and
- The operator is responsible for using the knowledge, skill and experience to do the job in the safest way.
One of the earliest Safety Board recommendations on corporate culture was issued in 1968, our second year of existence, to the Federal Railroad Administration. Following a review of a number of railroad accidents, we told the FRA that we believed that the primary responsibility for improved railroad safety should rest upon railroad management and labor. Our recognition then that safety and accident prevention are the responsibility of management, the individual workforce and government, holds true today.
But how should management fulfill its responsibility to assure safe operation? One role for management is to develop, nurture and maintain a healthy and safe corporate culture. In our practice of accident investigation at the Board, corporate culture issues fall within the organizational factors area. In the most elementary terms, we have treated the culture of any given transportation organization as their collective mindset. Let me give you a specific situation that defines the sort of mindset I'm referring to.
Consider this scenario: A transit train operator stops the train between stations and in doing so successfully avoids endangering the train and its passengers. However, stopping the train without permission violates an operating procedure. The operator calls the dispatcher to obtain permission but is told not to stop. He stops anyway.
But now, by stopping and avoiding the danger, the operator has no way to prove that an unsafe condition actually existed. The question is, what action does his superior take? Is the train operator disciplined reflexively for his disregard of the rules, or is he recognized for his alertness. I'll talk more about this situation when I describe an accident where an operator had to make just such a choice and he elected to conform to established procedures, with tragic results.
We at the Safety Board acknowledge that there are different ways to describe corporate culture; let me suggest one possible way of describing its basic components:
- The beliefs held by workers and managers in the organization about the way operations ought to work.
- The practices and customs that have become the norm, and
- How these various factors are valued either positively or negatively.
In our practice of accident investigation, we have found this concept useful.
Unlike some causal factors, it is not easy to identify corporate culture problems in the early days after an accident. For instance, it can be apparent soon after a train derailment that perhaps a broken rail initiated the accident. But it takes additional information and analysis to conclude that the train derailed because management had decided to postpone replacement of the defective rail.
As a matter of good investigative practice, it is never assumed that any accident operator's actions occurred in isolation. Each driver, engineer, pipeline operator or ship's officer performs the job in an environment of policies, procedures, operating limitations and operating latitudes.
One indicator for recognizing potentially unsafe cultures is management thinking and practices that are antagonistic or indifferent toward their employees in safety sensitive jobs. Another indicator is an organization's practices that vary from the accepted standards found in the industry. Third, an unsafe culture may exist if it is determined that an employee's operating performance conformed to carrier procedures or reflected the accepted values and attitudes found in the carrier and an unsafe situation still occurred.
Let me give you an example. Years ago our assessment of corporate culture focused primarily on whether management actively discouraged their operators -- in aviation, that would be pilots -- from following the established company and government rules and procedures. Yet, considering how much we have learned about corporate culture, it is difficult to accept the fact that accidents occurred because some companies actually encouraged rule breaking. For example, on May 30, 1979, a DeHavilland Twin Otter, operated by Downeast Airlines, a regularly scheduled commuter flight from Boston, crashed near Rockland, Maine, while the pilot was attempting to land in restricted visual conditions. Both pilots and all but one of the 16 passengers were killed in the accident.
The investigation found that the visibility was so poor that the pilot could not have been able to see the airport at the point, known as the decision height, at which he was required to abandon the approach if he could not see the airport. Why then did he attempt to land anyway, given the known hazards and prohibitions against such attempts? Well, further investigation found a corporate culture in place at that airline that not only did not enhance safety but actively discouraged it. The owner of the airline, who as president directed its day to day operations, conveyed to the captain and to all pilots his expectations that they would cut corners in the interest of saving money. In fact, he criticized and threatened them when they did not.
The lessons of this accident were unmistakable: a management climate that pressures pilots to ignore flight rules and safe operating practices, and threatens pilots if they do not conform to these practices, adversely affects the safety of the operation.
I want to offer you another example of corporate culture providing a negative influence on safety, the fatal collision on the Washington, D.C. Metrorail system in the Maryland suburbs. I alluded to this accident earlier.
For those of you who have not heard about this accident, it was a collision in January 1996 between two trains on Metro's Red Line. A moving train struck an unoccupied standing train that was not in service, killing the operator of the moving train.
This accident provided for our investigators markers of an organizational culture that considerably detracted from safe rail transit operation.
At first, it appeared that a train operator simply did not comply with his training. Then different pictures emerged suggesting that a superintendent at the train dispatching facility ignored warnings and did not stop the train. Later still, it appeared that an executive manager had acted capriciously when he changed a long-standing operating policy without consideration of the consequences.
This accident resulted not from singular actions but from an organization-wide set of beliefs held about the infallibility of the automatic train control equipment, somewhat reminiscent of the perceived infallibility of an ocean liner's watertight compartments so many years ago.
The Metro accident occurred shortly after a major snowstorm had begun and trains had started to overrun station platforms at several of the above-ground stations. The accumulating snow and ice reduced the effectiveness of the train's braking system. All trains were operating in the fully automatic mode; that is, they were being controlled by the system computer, not by the operator on board the train or by controllers in the system's central control facility.
Shortly after emerging above ground on its way to Shady Grove station, train 111 arrived at Twinbrook Station 12 minutes before the accident. Although the automatic train control directed the train to stop at the platform, the train did stop, but completely overran the platform.
At Rockville, too, the train partially overran the station. Because the operator had to secure the controls to assist passengers at that station, the train had lost its automated command to operate at the reduced speed of 44 mph. So, after departure from Rockville, the train began accelerating automatically beyond that speed, heading for 75 mph, still within the design limitations of the rails and signals, at least when weather conditions were favorable. The operator called the controller to report the over-speed situation and was told that this was due to his overrunning the previous station and that he was to continue in automatic operation.
As the train approached the Shady Grove station, the controller, who could see the location of the train on his monitor, called the operator and asked if the speed had dropped. Because it had, the controller later told Safety Board investigators that he had a feeling the system was doing what it was supposed to do and didn't believe that he had to put his job on the line by telling the operator to go into manual mode.
At Shady Grove station, a gap train was parked 470 feet beyond the platform on the same track that the accident train was using. A gap train stands by to fill in for unexpected needs, such as when a scheduled train breaks down. It was parked there despite an unwritten Metrorail order that these trains were to be kept on the adjacent inactive track.
You must know what happened next. When train 111 arrived at the Shady Grove station, it slid past the platform and struck the standing gap train. The operator was found crushed in wreckage near the cab door. There were no other injuries.
The Safety Board investigation team was launched that night. Once the follow-up investigation work began, a fairly clear picture emerged for what had happened and why. Here are several of the findings from our investigation that explain the accident and also have a direct connection to the organizational and management issues of interest to us today.
- Metrorail had recognized that leaving the gap train on the incoming active track presented an unnecessary hazard. But we learned that the gap trains were frequently stored on the active track, apparently because of confidence in the automatic train control system.
- There was no formal training program for controllers at the center, other than an annual operating rules examination. Consider that the controller knew of the accident train's overruns at two previous stations, he knew about the deteriorating weather, he knew about the unusually high speed of the train, and he knew the gap train was parked beyond the Shady Grove station. And yet he did not see a need to stop the train.
- Equally disturbing was our finding that no one, including the superintendent of the central control center, had the authority to intervene and stop the accident train unless a collision was certain. The controller felt that he would be putting his job on the line if he were to allow the operator to take manual control of the train, just as the Downeast Airline captain believed that his job, too, was on the line if he did not satisfy the president's wishes, even if they ran contrary to his better judgment about safety.
- Because manually operated braking was being blamed for a perceived flat-wheel problem, which would indicate poor braking technique, a decision was apparently made by the Deputy General Manager to eliminate all manual operation, even in inclement weather. No train operator knew of or was consulted about the change, and most of management including the General Manager did not learn of the decision until after the accident.
It would be tempting to blame the conditions and circumstances of this accident on one person, the Deputy General Manager. But this would not have recognized corporate culture as a safety problem. The logic for substantive causation of this accident only holds together when we consider the extent to which management and operating personnel believed the automated train control system would protect them, and that the system would provide adequate margins of safety regardless of the quality of the decisions and policies. Again, I am reminded of the mindset at the White Star Line leading up to the TITANIC disaster.
We made 20 recommendations to the Metrorail Authority as a result of the Shady Grove accident. Earlier this year, I met with Metrorail officials to discuss the actions on the Safety Board's recommendations from this accident, and it was apparent that major changes in Metrorail management and in their operating practices were taking place. Frankly, I was impressed by the aggressiveness of Metrorail management's actions on many of our recommendations, and at this time we have every reason to believe there will be an effective follow-through.
If you look at all of the accidents I've cited, their root causes go beyond a mere lack of planning or poor personnel decisions. Each of the accidents were set up by one or more of the following characteristics:
- Futility in the belief in an infallible technology.
- The lack of appreciation for the role of the human in a highly technical system.
- The lack of an avenue for divergent opinions.
- The arrogance of management that believed in its inherent superiority to government regulations and sound operating practices.
- The tradeoff between revenue and safety, to the detriment of safety.
- The establishment of an organizations culture that discouraged communication, divergent opinion, and an appreciation for the importance of safety.
There are a myriad other accidents that illustrate corporate culture failings in all modes of transportation; tragedies like the Ledger, Montana head-on train collision in 1991; the Brenham, Texas salt dome petroleum storage facility explosion in 1992; the crash of an FAA aircraft in 1993; and the Fox River Grove grade crossing accident in 1995. Through our investigations of these and other accidents, our understanding of the role of management in the safety of their organization's operations has increased.
We and the transportation community have come to recognize that management has responsibility for creating and fostering a climate that encourages safe operations. The purpose of your workshops today are for you to learn more about how best to ensure that a climate of safety remains paramount in your organizations' corporate cultures. I was very interested in this morning's exercise and I'm sure you all will benefit from the workshop this afternoon on Lessons Learned from Accidents. Marjorie Murtagh, the Chief of the Safety Board's Marine Division, will brief you on two major accidents we investigated.
Your presence here is important, not just because many of you are leaders of your organizations, but because you will have to be leaders of the maritime industry. The practice of good corporate culture is not just good for safety, it is good for business. But you will have to show the way for others, because it only takes one or two bad apples to sully the reputation of an entire industry.
Thank you for inviting me.
Jim Hall's Speeches