Thank you, sincerely, for inviting me. As a safety culture junkie, I’ve thoroughly enjoyed the discussions this morning. And, I truly applaud the efforts of the American Short Line & Regional Railroad Association to enhance safety culture within the industry.
NTSB has had a long-standing interest in safety culture and its role in transportation safety. 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. In 2013, after seeing continued accidents attributed to deficiencies in safety culture, we hosted another forum on safety culture. And, I can tell you, we are still seeing accidents where the way business was done wasn’t consistent with a healthy safety culture. Just yesterday, we held a board meeting on a business jet crash that claimed seven lives at Bedford, Massachusetts. Our report didn’t specifically use the term “safety culture,” but I can say that although the operator had all the appearance of a strong safety culture, when we peeled back the layers of the onion, even basic things like procedural compliance with cockpit checklist usage were absent.
I believe that by focusing on safety culture, you are focusing on something that can pay tremendous dividends. As a business major, I intentionally used a financial term here because I firmly believe that good safety correlates positively with good financial performance.
Let me ask you a very simple question: Does the short line and regional railroad industry have a good safety culture?
Not that I want to give you indigestion after we’ve just eaten lunch, but in the words of Professor Jim Reason, “… it is worth pointing out that if you are convinced that your organization has a good safety culture, you are almost certainly mistaken…. A safety culture is something that is striven for but rarely attained… [and] …the process is more important than the product.”
What I believe Dr. Reason is saying that we don’t want to be too smug with believing we are “there.” First of all, there is no “there”: safety culture is not a destination, it’s a journey. Once we start thinking we are “there,” we get complacent and things can bite us. He mentions that a chronic unease is what keeps us on our toes. So, while I certainly hope you do have a good safety culture, I don’t want you to sit back and start believing you are where you should be.
I suspect many of you know my good friend, Jim Schultz. Jim talks about “good can be bad.” His point is, and I quote here, “with good safety performance, people/organizations can easily become complacent. Don’t ever believe that a lack of accidents means you are ‘safe.’ To counter this complacency, there must be a leadership obsession with continuous improvement.”
I couldn’t agree more with Jim. When I was running a small flight department for a Fortune 500 company, I would wake up at 3:00 in the morning in a cold sweat. I would be worrying about something happening in our department. And, I would try to act on those concerns to alleviate them. That chronic unease keeps us on our toes.
You’ve already heard excellent perspectives this morning on safety culture, and I knew there would be no way I could provide all of my thoughts on this important topic in just 15 or 20 minutes. After all, there are so many stepping stones along the pathway to a strong safety culture and I feel each of them is critical. However, given the time constraints, I decided to focus on what I consider to be the first and foremost element of safety culture – leadership.
Safety culture begins with leadership and it has to permeate throughout the entire organization. If the leaders aren’t truly committed to it, you sure won’t get others in the organization to buy into it.
By way of example, in the investigation of the 2009 Washington Metropolitan Area Transit Authority (WMATA) Metro accident here in Washington, DC, the NTSB cited “WMATA’s lack of a safety culture” as a contributing factor in the accident.
How did inadequate safety leadership play a role in that accident? Well, to begin with, the highest level of WMATA leadership – the board of directors – did not even have safety promotion or anything related to safety in their charter. Their then-chairman testified to NTSB that they were a policy board and oversight was not their role. They were only aware of those safety concerns brought to them by the WMATA general manager. So, as far as the board of directors was concerned, no news was good news.
Furthermore, the metrics that the WMATA board of directors used to measure safety were things like crime in subway stations; escalator injuries;, and slips, trips, and falls. Although these are important topics, they had no relevance to anticipating and preventing this type of accident that killed nine people and injured dozens others. The NTSB found that “ineffective safety oversight by the WMATA Board of Directors” was a contributing factor in the accident.
So rhetorically speaking, how do you ensure safety permeates the entire organization and is a consideration for everything you do? Again, I can’t emphasize enough that it begins with leadership.
To quote best-selling author John Maxwell, “Leadership is about influence. Nothing more. Nothing less.”
In the NTSB’s report of the WMATA accident, we stated that “the safety behaviors and attitudes of individuals are influenced by their perceptions and expectations about safety in their work environment, and they pattern their safety behaviors to meet demonstrated priorities of organizational leaders, regardless of stated policies.”
In other words, people will watch you and they do what they think you want, and not necessarily what you tell them you want.
As you are well aware, between May, 2013 and March, 2014, Metro-North experienced five accidents that were investigated by the NTSB. These accidents collectively resulted in six lives lost, 126 injuries, and more than $28 million in property damages.
During the investigation of these accidents, a senior VP at Metro-North told NTSB investigators: “We were geared towards using the on-time performance numbers as a metric. The philosophy was that if we can deliver trains on time, all of the supporting activity that we did, track maintenance, signal maintenance, and rolling stock maintenance must be performing well if we can deliver that high degree of service reliability.”
With on time performance being a key performance metric, it should be no surprise that, in separate investigations, FRA and NTSB independently found that pressures of on-time performance were felt throughout the system. One employee commented to NTSB: “It’s all about on-time performance and safety rules are thrown out the window to keep on-time performance. Management has no clue.”
So, despite management rhetoric that safety was so important, the message employees perceived was: “Safety is important – as long as it doesn’t affect schedule.”
As a leader, what message are you sending? Is safety just talk in your organization, or are the leaders actually walking the talk?
I challenge you to give serious consideration to that question. If you’re not sending the right message, I urge you to make changes. After all, safety culture begins with leadership, and you are the leaders in the industry.
Thank you and keep up the good work.