Attributes of a Healthy Safety Culture

By Chairman Robert L. Sumwalt

I recently wrote a series of social media messages about attributes of a healthy safety culture. I received some interesting feedback and cross-talk from organizational safety leaders, so I wanted to make the collected messages available in PDF form for this blog’s readers.

Attributes of a Healthy Safety Culture

Click on any of the attributes listed below to read the original messages.

I hope that, after viewing these messages, readers look around their operations, note where an attribute is lacking from their organization’s safety culture, and consider whether the shortcoming presents an opportunity for improvement. As widely known expert on organizational accidents James Reason said, “There are no final victories in the struggle for safety.”

While writing these messages, I realized again how integrally enmeshed personal and organizational responsibility are in the safety journey. The active error committed by one employee might not have been committed by another, but the same employee who committed the error might not have done so in another organization. Furthermore, in addition to individuals, an organization might be at the root of an accident.

Continuous safety improvement takes both conscientiousness and boldness to voluntarily identify what might go wrong and to think through the “what ifs” on the way to mitigating risk. It’s a tall order, and my hat is always off to those who accept the challenge—our safety professionals.

I hope that these musings will be of value to you and your colleagues as you move forward in your safety journey!

Automated Vehicles and Distraction: Lessons Learned from Mt. View

By Robert Molloy, PhD, Director, NTSB Office of Highway Safety

The National Transportation Safety Board (NTSB) met on February 25 to consider the 2018 collision of a Tesla Model X, operating with partial driving automation, with a damaged crash attenuator in Mountain View, California. The car steered out of its travel lane and into a gore area, where it collided with the damaged highway safety hardware. The driver didn’t notice the errant path the vehicle had taken because he was interacting with a game application on his work phone.

March 23, 2018, crash of a Tesla in Mountain View, California
Northbound view of the crash scene before the Tesla was engulfed in flames. (Source: witness S. Engleman)

It was a tragic event for both the driver and his loved ones, and the tragedy was compounded because the event was utterly preventable. In this crash, the driver behaved as if his partially automated vehicle were self-driving when it wasn’t. The driver’s resulting distraction, tragically, led to his death. But it’s rare that a crash is the result of a single factor. At the NTSB,  we try to identify all the factors contributing to a crash so we can propose multiple methods to prevent a similar crash in the future. The NTSB doesn’t apportion blame or liability; we look for ways to prevent the next occurrence.

In this crash, we identified or reiterated several ways to prevent a similar tragedy:

  • Because drivers using portable electronic devices while driving often crash, we recommended that device manufacturers find a way to lock people out of their devices while they’re driving.
  • Because “Autopilot,” Tesla’s automated vehicle control suite, is only designed for certain conditions, we reiterated our recommendation to disable it when those conditions are not met.
  • Because Tesla’s proxy measure for driver engagement—torque on the steering wheel—was previously found ineffective, we reiterated a recommendation that Tesla find an effective measure of driver engagement.
  • Because this vehicle crashed into objects that it “did not detect, and [were] not designed to detect,” (a crash attenuator) we recommended that the National Highway Traffic Safety Administration (NHTSA) rate collision avoidance systems under its 5-star rating program, incorporating such objects into its assessment.
  • Because we found that misuse of Tesla’s automation was foreseeable, we recommended that NHTSA evaluate Tesla Autopilot-equipped vehicles to determine if the system’s operating limitations, foreseeability of driver misuse, and ability to operate the vehicle outside the intended operational design domain pose an unreasonable risk to safety, and to ensure that Tesla takes corrective action if safety defects are identified.
  • Because the crash attenuator that the Tesla crashed into had not been repaired, and because lane markings were worn in the area of the crash, we made recommendations to state agencies responsible for maintaining highway infrastructure.
  • Because Apple, the driver’s employer, had no distracted driving policy, we recommended that it adopt one.
  • Because many other companies also don’t have such a policy, and because transportation accidents are a leading cause of workplace injury and death, we recommended that the Occupational Safety and Health Administration review and revise its distracted driving initiatives and add new enforcement strategies.
  • Because it is important to have ready access to data that fits defined parameters to assess crashes involving automated vehicle control, we reiterated recommendations to require standardized data reporting, including incidents, crashes, and vehicle miles traveled, with such systems enabled. This recommendation would also allow the NTSB and NHTSA to evaluate real data on the safety of level 2 automation, not just industry claims.

When we investigate a crash, we aren’t looking for a driver, a company, or an agency to blame; we’re looking for all the ways the next crash can be prevented. When prevention is the goal, those drivers, companies, and agencies are often happy to help make the changes needed to ensure safety. We hope all parties will heed the lessons learned from this tragic crash and take the steps we’ve recommended to increase the safety of the traveling public.


A Comprehensive Approach to Bicycle Safety

By Member Jennifer Homendy

Last fall, the National Transportation Safety Board released a report that made safety recommendations meant to improve safety for an important and growing segment of users on our roadways – bicyclists. The report issued 12 new safety recommendations and reiterated 10 safety recommendations.

Through NTSB’s 50+ years of accident investigation experience, we’ve long known that complex challenges, like reducing the number of vehicle-bicycle collisions, requires multi-faceted solutions. In the study, we looked at numerous countermeasures, including roadway design and infrastructure, reducing traffic speeds, collision avoidance systems and blind spot detection systems.

Homendy-bikePerhaps that is why I was disappointed to see the controversy within the cycling community surrounding one of the 22 recommendations discussed in the report – the singular recommendation about requiring the use of helmets. That debate overshadowed the many other important recommendations that largely focused on preventing collisions between vehicles and bicyclists in the first place, rather than mitigating their severity. As an avid cyclist myself, I am very aware of the hazards that exist for cyclists and share the community’s concern for improving bicycle safety on U.S. roadways.

Separated bike lanes and bike-friendly intersections are incorporated in the design of just a tiny fraction of U.S. roadways. So, we asked for more. The NTSB recommended that guidance provided to highway engineers, city planners and traffic designers, include resources that will help increase bike-friendly roadway improvements throughout the U.S.

Along with changes in infrastructure, the NTSB found that reducing traffic speeds can reduce the likelihood of fatal or serious bicycle injuries. Lowering speed limits is part of a safe systems approach that was also discussed in our 2017 safety study on reducing speeding-related crashes.

Collision avoidance systems are broadly effective in helping motorists detect and avoid other vehicles and some automakers have begun adding systems to detect bicyclists and pedestrians.  To encourage manufacturers to include these systems in their new vehicles, and to assist auto buyers in making safety-conscious purchasing decisions, the NTSB recommended that bicycle detection systems be incorporated into the 5-Star Safety Ratings.

The NTSB also recommended that newly manufactured large trucks be equipped with blind spot detection systems, because large vehicles have bigger blind spots that make it difficult, or even impossible, in some situations for their drivers to see bicyclists.

And as a Board Member, I will continue to push for the implementation of safety recommendations on the NTSB’s Most Wanted List that would help make streets safer for bicyclists – including eliminating distractions, reducing fatigue-related accidents, ending alcohol and other drug impairment, increasing implementation of collision avoidance systems and reducing speed-related crashes.

Member Homendy Bike Safety Study Board Meeting

Implementation of our recommendations would dramatically improve the safety of our roadways for bicyclists. But prevention or avoidance will sometimes fail and mitigating the severity of crashes will help save lives. That basic premise of transportation safety, supported by data on fatalities from head injuries, prompted our call for helmets for bicyclists.

The NTSB’s approach to bicyclist safety is comprehensive, multi-faceted and fact-based. All the safety recommendations, when implemented, would help save lives by preventing collisions from happening, and by reducing the severity of those that do.