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.
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!
By: Nicholas Worrell, Chief, Office of Safety Advocacy
After 21 years, the Safe Skies for Africa (SSFA) program officially came to an end last week at a symposium in Lagos, Nigeria. The program was established in 1998 in part to increase direct commercial air service between the United States and Africa, which was minimal at the time. Administered by the US Department of Transportation and funded by the US State Department, the SSFA program has accomplished many of its original objectives since inception, including improving the safety and security of aviation on the African continent. Over a dozen symposia and workshops have been held over the life of the program, and we organized past SSFA symposia with the South Africa Civil Aviation Authority and Kenya’s Air Accident Investigation Department. This year’s event was hosted by the Air Investigation Bureau-Nigeria (AIB-N), who also sent a team of accident investigators and industry representative to participate.
Former NTSB Managing Director (and program pioneer) Dennis Jones spent nearly 20 years in the SSFA program, participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators. In his opinion, the Safe Skies program has done what it was created to do. At the outset of the program, few African airlines and hardly any US airlines were flying to Africa, even though it’s the world’s second-largest continent. Today, two US carriers provide direct service to Africa, and six African countries (Egypt, Ethiopia, South Africa, Morocco, Cape Verde, and Kenya) have direct routes to the United States.
Along with increased US commercial air service to Africa, air investigation quality has improved, resulting in a lower accident rate and greater safety in commercial aviation in Africa. Many African nations now have their own accident investigation agencies, and some are even developing multimodal agencies based on the NTSB model.
We were honored to again join other NTSB communications specialists and experts, as well as former NTSB Managing Director Dennis Jones, for the final symposium. The symposium focused on the following topics:
The NTSB’s background and history
Emerging aviation safety issues
The investigative process and human factors
Accident classification and substantial damage
The challenges of providing family assistance
Effective safety advocacy: creating positive change in transportation safety
Our team shared lessons learned from NTSB accident investigations, as well as strategies to help our international counterparts take steps in their own aviation safety journey. The AIB-N participants were focused and receptive to our presentations, and the event was bittersweet as we parted ways with old colleagues and brought the program to a close.
Although the SSFA program has resulted in many improvements over its 21 years, more remains to be done. Safe and reliable aviation connects people all over the world, in more ways than you may realize. Aircraft components, engines, and airframes come from manufacturers all over the world. The airplanes they comprise might be flown by airlines in any country. We are all stakeholders in aviation safety, regardless of what continent we inhabit.
We look forward to more programs like SSFA that will advance international collaboration on aviation safety issues. I’m confident that new safety ambassadors will follow in the footsteps of those who participated in the SSFA program, and I look forward to working with the pioneers who participate in these programs going forward.
For our blogs on the other NTSB SSFA symposia in South Africa and Kenya, please see links below:
Last week, I kicked off Safe and Sound Week—an Occupational Safety and Health Administration initiative—with this video message. In the video, I reminded NTSB employees that one of the things our agency does is meet with victims’ family members on perhaps on the worst day of their lives. I told my colleagues that I’d consider it the ultimate failure to ever have to sit down with any of their family members to tell them that something bad had happened to them while they were on the job at the NTSB.
Workplace safety is not included in the NTSB’s statutory mission, but it certainly is “in our lane,” just as it’s in any organization’s lane. I believe workplace safety should be built into how we think and act at the NTSB. Our agency’s Occupational Safety and Health Program team recently challenged all of us to define what safety means. My answer was, “constantly anticipating bad things that can happen and then proactively taking actions to mitigate those things so that no one gets hurt.”
That answer was based on, among other things, a particular personal experience. I remember a street crossing near my home that was adjacent to a blind curve obstructed by shrubbery. It seemed a little dangerous, but I never really thought much of it until I had to dart back to the curb to avoid being struck by a car. After that, I found another crossing point about 15 feet away that was a little safer. Why hadn’t I found that safer crossing sooner? Because I hadn’t been constantly anticipating what could happen and working to mitigate the danger.
Now, take an example of the same lack of risk assessment to a broader scale. We recently completed our investigation of an accident near DuPont, Washington, where a transit train on its inaugural revenue service run failed to slow down from 78 mph when entering a curve with a speed restriction of 30 mph. The train derailed, sending several cars plummeting to the interstate below. Three passengers were killed, and 55 people were injured—including 8 in vehicles on the road. The transit agency responsible for assessing risk on this curve had determined one mitigation prior to the derailment: implementing positive train control (PTC); however, PTC implementation was delayed, and the transit agency didn’t find another means of mitigating the risk before carrying on with the inaugural run.
Just like me crossing the street near my home, the transit agency was not constantly anticipating what could happen and taking action to mitigate the worst-case scenario. That lack of action put not only the train’s passengers at risk, but the agency’s employees, as well.
Workplace safety doesn’t fall solely on an organization’s management, though. It’s a shared responsibility between an agency and each of its employees. Ask your workplace safety experts what to look for when assessing your workplace for safety risks. In my agency, the risks vary widely from an accident scene to the office, but we strive to address all possible scenarios to keep ourselves—and each other—safe. Wherever you work, slips, trips, falls, fire hazards, and other workplace safety concerns are undoubtedly “in your lane.” It’s up to all of us to assess our workplace risk and take actions to mitigate it.
By Captain James Scheffer, Strategic Advisor, NTSB Office of Marine Safety
I’m often asked how the NTSB chooses which marine accidents to investigate, and what role the US Coast Guard (USCG) plays in our investigations. I had the same question when I first joined the NTSB’s Office of Marine Safety more than 20 years ago. The NTSB has specific authority under the United States Code and Code of Federal Regulations to investigate “major marine casualties.” These are accidents involving vessels that result in one or more of the following:
The loss of six or more lives.
The loss of a mechanically propelled vessel of 100 or more gross tons.
Property damage initially estimated as $500,000 or more.
Serious threat, as determined by the USCG Commandant and concurred with by the NTSB Chairman, to life, property, or the environment by hazardous materials.
Our authority to investigate covers major marine accidents on US waters or those involving US-flagged vessels worldwide. We also have the authority to investigate casualties involving public (owned by the United States) and nonpublic vessels. In these casualties the threshold is defined by at least one fatality or damages of $75,000 or greater. Our task in these investigations, whether a major marine casualty or a public and non-public casualty, is to determine the probable cause of the accident and identify safety recommendations that will prevent similar events in the future. We also investigate, independently or with other government agencies, marine accidents in which the United States is a substantially interested state (SIS), according to the International Maritime Organization’s “Code for the Investigation of Marine Casualties and Incidents.”
So, where does the USCG fit in? The USCG conducts preliminary investigations of all marine accidents, then notifies us when an accident qualifies as a major marine casualty. Unlike in other modes of transportation, such as aviation, where the NTSB leads the investigation, the USCG typically takes the lead in marine casualty investigations. Under a memorandum of understanding (MOU) between the NTSB and USCG, however, the NTSB may become the lead federal agency for the investigation, depending on the circumstances. This may occur when there is a significant marine accident that is a subset of a major marine casualty and is defined in the MOU as the following:
The loss of three or more lives on a commercial passenger vessel.
Loss of life or serious injury to 12 or more persons on any commercial vessel.
The loss of a mechanically propelled commercial vessel of 1,600 or more gross tons.
Any marine casualty with loss of life involving a highway, bridge, railroad, or other shore side structure.
Serious threat, as determined by the USCG Commandant and concurred with by the NTSB Chairman, or their designees, to life, property, or the environment by hazardous materials.
Significant safety issues, as determined by the Commandant and concurred with by the Chairman, or their designees, relating to Coast Guard marine safety functions.
If a marine casualty meets any of the above significant marine accident criterion the NTSB may elect to be the lead federal investigative agency.
In marine casualties involving a public (federal government) and a non-public vessel, if the vessel is Coast Guard the NTSB must investigate and be the lead federal agency. With casualties involving other public and non-public vessels, in most cases, the NTSB investigates as the lead federal agency.
The Office of Marine Safety typically investigates 30 to 40 marine accidents per year meeting the above criteria, and we do so with a staff of only 21 people, including investigators, writers, support staff and supervisors/managers. To get an overview of the Office of Marine Safety’s work, take a look at our Safer Seas Digest, which can be found on our ntsb.gov website, and summarizes our recent accident investigations and findings.
Let’s face it: the NTSB isn’t an agency that often has good news to report. As an accident investigation agency, we deal with the hard facts regarding terrible shortcomings in our nation’s transportation system. This week, however, I’m pleased to report some good news.
On Wednesday, the Partnership for Public Service released its annual “Best Places to Work in the Federal Government” rankings. The overall rankings are determined by the Best Places to Work employee engagement score, which is calculated using a proprietary formula that looks at responses to the US Office of Personnel Management’s Federal Employee Viewpoint Survey. For the third straight year, NTSB ranked among the top 10 small agencies in the Partnership’s Best Places to Work in Federal Government rankings. We maintained our 2017 rank of number 6 out of 29 small agencies (in 2017, 28 small agencies were assessed). I take great pride in working with the fine men and women of the NTSB who allow this agency to be such a great place to work. That said, our goal is to be even better, and our leadership team is committed to making that happen.
The second piece of good news revolves around a very special recognition for one of our senior leaders. Last evening, NTSB Chief Financial Officer Edward Benthall, Jr, received the prestigious Presidential Rank Award (PRA). Two categories of rank awards are available: “Distinguished,” for leaders who achieved sustained extraordinary accomplishments, and “Meritorious,” for leaders who have achieved sustained accomplishments. Ed joins a list of only 45 other 2018 Distinguished PRA recipients.
Bestowed by the President of the United States, the PRA is one of the highest awards conferred to Career Senior Executive Service (SES), Senior-Level (SL), and Scientific-Professionals (SP) within the federal government. The review process is extensive, and candidates are vetted with a federal background investigation. Names of the finalist are sent to the White House for final selection.
Ed was recognized for his work to safeguard the NTSB’s financial status and stellar reputation. He and his team have worked tirelessly to ensure that, for the 16th consecutive year, the NTSB received a clean (unmodified) financial audit opinion from outside auditors. When I announced to NTSB employees last week that Ed would receive the PRA this year, Ed brought his team front and center to acknowledge their contributions.
What’s amazing to me is that this is the fourth consecutive year that the NTSB has had a Distinguished PRA recipient. Considering that the Distinguished PRA is only bestowed to fewer than 50 employees government-wide each year, and considering that we have only about 20 SES, SL, and SP employees, this record speaks volumes for the fine caliber and dedication of our employees. With leaders like this, it’s no wonder the NTSB is one of the best places to work in the federal government.
On February 10, 2018, an air tour helicopter descended into a canyon wash and collided with terrain while on approach to land at Quartermaster landing zone in the Grand Canyon near Peach Springs, Arizona. As part of this ongoing investigation, NTSB engineers needed a three-dimensional (3D) digital model of the accident site and surrounding terrain to thoroughly understand the terrain features in the local area. Although the main effort involved the use of a FARO laser scanner to create the 3D model, the NTSB small unmanned aircraft systems (sUAS) team recognized an opportunity to exercise our sUAS imagery-collection capabilities using photogrammetry and sUAS in a challenging environment to support this investigation and allow for a comparison of the data gathered from the two techniques for future investigations.
Since 2016, the NTSB has used sUASs, or drones, to create orthomosaic maps of wreckage sites and provide 3D digital models of terrain and vehicles for use by investigators in all transportation modes. Recently, we’ve launched the drone team to rail accidents (including the Hyndman, Pennsylvania, and Alexandria, Virginia derailments) highway crashes (including the Amtrak grade crossing collision with a refuse truck in Crozet, Virginia), and aviation accidents (including the crash of a cargo airplane in Charleston, West Virginia; the rejected takeoff and runway excursion at Willow Run Airport in Ypsilanti, Michigan; and multiple general aviation accidents at sites across the country). None of these missions, however, presented terrain challenges like those in the Grand Canyon.
Because the Grand Canyon is a combination of National Park Service and tribal lands, planning for the mission started weeks in advance. We needed to obtain permission from various tribal and governmental entities to operate a drone within that airspace and the special flight rules area (SFRA). The area is heavily used by numerous helicopter tour operators in the region, so planning involved coordinating with and notifying the various local operators of our intended sUAS mission. Without the support of the Federal Aviation Administration, the Hualapai Nation, the National Park Service, and Papillion Helicopters, this mission wouldn’t have left the ground.
After we received the appropriate approvals, we assembled in Boulder City, Nevada, to load a helicopter for the short trip into the canyon. Unlike other sUAS missions I’ve conducted, the remoteness of the canyon location introduced many challenges. For example, at the site, there were no electrical outlets or a generator, so we needed to plan the mission carefully in advance to ensure that it could be completed within the flight time enabled by the available batteries—recharging was not an option. Also, cellular coverage (including wifi) was nonexistent; thus, we had to access the Internet for the ground station software before departing for the canyon. In addition, when we use the sUAS to map an accident site, we use ground control points (GCPs) that we typically mark with paint. However, out of respect for the sacred land of the Hualapai Nation where the operation took place, we instead used lightweight, removable targets as GCPs. In total, I took 65 pounds of gear into the canyon to support the sUAS operation.
We conducted the sUAS flight early in the morning in light wind conditions suitable for drone flying and low temperatures, which was welcome compared to the triple-digit temperatures expected later in the day. We conducted our flights concurrent with the laser‑scanning effort in the canyon wash. As remote pilot in command (RPIC), I arranged for our helicopter pilot to work with me as the visual observer (VO) for the mission. The VO monitored the local traffic frequency for inbound and outbound traffic and relayed information back to me. During a few flights, I paused the mission to land the drone to ensure safe separation from tour helicopters. We accomplished the mission in just over an hour of sUAS flying time, which included a 12-minute, 10-acre mapping mission. The effort provided a detailed 3D model of the canyon wash for the engineers and stunning visual imagery of the local terrain area. The data are currently being analyzed by investigative staff.
Through this investigation and others, we’ve found that the ability to create 3D models of accident scenes is a valuable tool in the investigator’s tool box. Moreover, the ability of the sUAS to provide the imagery needed for these models in unique, complex environments in a short time and with low acquisition cost will aid our investigators for years to come. The NTSB sUAS team continues to explore the possibilities of sUAS imagery collection within the envelope of safe drone operations to further understand the capabilities and limitations of the technologies as they relate to the agency’s mission.
Michael Bauer is an aerospace engineering investigator in the NTSB Office of Aviation Safety.
I don’t know about you, but it seems that every day I see more and more people traveling by bicycle; whether they’re riding for exercise, taking a fun ride with family and friends, or commuting to work. It’s exciting to see a growing population using bicycles to get from place to place. People are also bicycling year-round, in all types of weather, across the United States. As someone with a background in public health, I’m glad to see that The League of American Bicyclists reports that bike riding is an increasing trend. Personally, I always look forward to participating in Bike to Work Week and Bike to Work Day each May during Bike Month.
I love my bike. It isn’t anything fancy, but it gets me where I need to go, and it was even recently featured in the New York Times. My family and I ride our bikes as often as possible. Some of my colleagues at the NTSB (you can see some of us in the photo) have been biking to work for years. Many of us are lucky to live in Bicycle Friendly Communities where it is easy to travel by bicycle around town.
The NTSB is known for investigating every civil aviation accident and significant accidents in other modes of transportation—highway, rail, pipeline, and marine. Our goal is to help people get around—in whatever form of transportation they choose—as safely as possible. One of the tools we use to achieve this goal is the “Most Wanted List” of transportation safety improvements (MWL). Although neither our investigations nor the MWL have a specific focus on bicycles, many of our recommendations and the MWL items can improve safety for bicyclists. For example, when decisions are made with the safety of all road users in mind, such as following NTSB recommendations for a safe systems approach to setting speed limits or lowering the per se BAC limit to 0.05 g/dL to prevent drinking and driving, those of us who ride bicycles are safer. Additionally, when we make roads safe for the most vulnerable users, such as people who walk and bike, everyone benefits.
I encourage anyone curious about commuting by bicycle to give it a try this Bike to Work Week. You’ll be in good company (and if you see one of us from the NTSB on our bikes, be sure to say hello). According to the League of American Bicyclists, many people who participate in the Bike to Work Day promotion for the first time become regular bike commuters! Give it a try—map your route, get your bicycle tuned up, and always remember to wear your helmet!