Category Archives: Inside NTSB

We Can Do Big Things. Just Look at Positive Train Control

By Member Jennifer Homendy

After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country!

This video highlights the NTSB’s more than 50 year effort in investigating PTC-preventable accidents and advocacy for this life-saving technology.

PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than 300 people, and injured more than 6,800 passengers, crewmembers, and track workers in major accidents stretching across the nation, from Darien, Connecticut, in 1969, to Chatsworth, California, in 2008, to Philadelphia, Pennsylvania, in 2015, and DuPont, Washington, in 2017.

But let’s step back and marvel at this real achievement—and the effort it took. Safety improvements are never easy or quick. It took more than 50 years of advocacy by the NTSB and historic action by Congress to make PTC a reality. For many of these years, the NTSB was a lonely voice for safety, pushing for PTC despite opposition from railroads over the price tag and technological hurdles.

I know how tough the battle was because I was there. As staff director for the House subcommittee charged with overseeing rail safety, I played a role in ensuring that any effort to move legislation forward to improve rail safety included the NTSB’s recommendation to implement PTC. When I got to the NTSB, one of my priorities was to ensure that mandate was implemented.

It truly is remarkable in Washington to keep such clear focus on PTC across so many administrations, through so many changes in Congress and at the NTSB.

Earlier this month, I had the honor of moderating a panel of current and former NTSB leaders and staff who recalled the long, bumpy road to PTC implementation. NTSB Chairman Robert Sumwalt and former agency heads Chris Hart, Debbie Hersman, and Jim Hall recalled their own contributions and noted how remarkable the agency’s sheer persistence was in a time of short attention spans and quickly changing priorities.

It was so uplifting to hear their personal reflections of their time on the Board fighting for PTC, and their continued commitment to the agency and its critical safety mission. But it was the staff panel that really defined persistence. Generations of rail investigators and other staff worked every one of the 154 PTC-preventable accidents over the decades, launching to horrific crash scenes only to discover similarities pointing to the same solution: PTC. They spent holidays working. Missed birthdays and anniversaries. Completed their important jobs regardless of on-scene obstacles and personal priorities.

Recording of the January 14, 2021, NTSB live‑streamed discussion about Positive Train Control implementation.

The public doesn’t often see what goes on behind the scenes at accident investigations, after investigations are completed when recommendations need to be implemented, and the tremendous work required to keep those recommendations at the forefront of discussions to improve safety. As stated in the first panel, board members come and go, but it’s the staff that keep these critical safety issues alive. It was truly remarkable and heartwarming to hear their reflections of the agency’s work and how that work has impacted public safety, as well as how it affected them personally. I hope it gave the public a sense of what it takes to stay focused on an issue for five full decades.

Was it worth it? You bet. PTC will save lives.

Other safety improvements have also taken many years to implement. Midair collisions were dramatically reduced by the Traffic Alert and Collision Avoidance System (TCAS). That took decades to put in place. Airliner fuel-tank inerting systems, which addressed fuel tank explosions like the one that brought down TWA Flight 800 in 1996, also took years. And let’s not forget about the long fight for airbags and seat belts in passenger vehicles. All these transportation safety improvements were strongly and relentlessly advocated for by the NTSB.

We can do big things in America. We can save more lives on our rails, in the sky, in communities where pipelines are located, on the water, and on the highway. But major safety improvements like PTC take time, money and, perhaps most of all, incredible perseverance.

Where the Action is in Safety

By Dolline Hatchett, Director, Office of Safety Recommendations and Communications

As the Director of the NTSB’s Office of Safety Recommendations and Communications (SRC), I lead a group that is focused on getting the whole story of accident investigations to the public. When there is a transportation disaster, my group is on scene alongside the frontline investigators, recording B-roll (video imagery of the accident site), and helping prepare NTSB spokespeople for on-scene press conferences.

But that’s just the leading edge of the investigation—and of our communications responsibility. For major investigations, we also focus attention on the public Board meeting. And, equally important but often overlooked, we help craft safety recommendations and advocate for them to be enacted, following up with recipients—sometimes for years—to see the job through.

My division’s mission runs the gamut, from fine points of grammar and usage to getting the right information out so that the people who need it have access to it. And lately, I’ve been thinking about how our language affects how we think—and what we do—about safety.

The Chairman of the NTSB has said that safety is not something that you can get or own, it’s something that you do, day after day. How does that relate to how we talk and write about safety? Well, if safety is something that we do, it’s not safety the noun (or the modifiers safe or safely). At heart, safety is a verb: to save.

To save lives. To save people from injury, and to save property and the environment from damage. How do we do this? By identifying hazards and mitigating risk (more action words—things we do to save ourselves, others, and our world!).

Why is this important? I notice too often that things that we do “for safety” are easily waved off. They’re thought of as things we do just in case something unlikely happens, but that cost time and money for the usual case when those measures aren’t needed. But the unlikely occurrence is out there, ready to happen, if that procedure isn’t followed or that safe design fails. We can’t be lax about safety, even if the likelihood of something going wrong is very low.

Those who are not deeply passionate about safety might dismissively explain that a feature is “for safety.” Think about the last automobile commercial you saw. I’m certain you heard something like “safety features” mentioned as flashy footage of that new car raced around coastline curves. I bet you weren’t thinking at all about what that term—safety features—even meant. It wasn’t made out to be as important as the car’s horsepower or built-in infotainment system. But what if the commercial narrator used a different term? Would you pay more attention if the narrator said, “To save your life, this vehicle is equipped with . . .” before summarizing the car’s safety features?

As you may have concluded, I truly appreciate the power of verbs—as far as language goes, they’re where the action is, where the rubber meets the road. By the same token, safety recommendations are where the rubber meets the road in the NTSB’s mission to improve safety. They’re about actions that can be taken to save people from death or injury, or to save property or the environment.

For example, although we recommend and advocate for transportation operators to use safety management systems (SMSs), implementing an SMS means starting and continuing a process. Although this process does include documents (safety policy), it does not begin and end there. A company must also do safety every day. Complying with rules is a good foundation, but to move ahead in a safety journey, we need the verb to save, which means making an ongoing, active effort. What does it mean to continually save in all that we do? It means following all the safety rules, of course, as a first step. But it also means continually scanning the horizon for the next hazard, to save lives, save others or ourselves from injuries, and save property and the environment from damage. This continual vigilance aligns with the proactive, recurring feedback necessary for a successful SMS.

We can all take a page from the safety professional’s book and forget safety the noun. Especially in today’s environment, safety is not something that we get or own. It’s something that we do, and continue to do, every day.

Safety is, by all rights, a verb. It calls for action. Make safety something you do, and keep doing it.

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!

Safe Skies for Africa Ends, but the Safety Journey Continues

By: Nicholas Worrell, Chief, Office of Safety Advocacy

August 2019 Safe Skies for Africa symposium, Lagos, Nigeria
NTSB staff and attendees at the Safe Skies for Africa symposium in Lagos, Nigeria

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
  • Helicopter operations
  • 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:

https://safetycompass.wordpress.com/2018/08/09/ntsb-supports-safe-skies-for-africa-initiative/

https://safetycompass.wordpress.com/2018/10/01/another-step-toward-safer-skies-in-africa/

 

Safe and Sound at Work

By Chairman Robert L. Sumwalt

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.