Safety culture in transportation

A fatal train collision near Washington, D.C., in 2009.

A severe pipeline rupture in Marshall, MI, in 2010.

A fatal flight test of an experimental aircraft in Roswell, NM, in 2011.

Although seemingly unrelated, these major transportation incidents share a primary contributor: an ineffective safety culture at the companies responsible, according to investigators at a National Transportation Safety Board forum that took place Sept. 10-11.

Investigators stated that in each incident, workers had been made aware of safety hazards or processes months or years before disaster struck. These hazards or processes included malfunctioning train control systems, five-year-old corrosion on a crucial segment of pipeline and evidence of unsafe wing design on the experimental aircraft.

Reasonable transportation workers do not wake up and intend to be unsafe, said forum moderator Deborah Hersman, chairman of NTSB. But what leads them to make unsafe decisions, and how can regulators influence safety cultures to reduce the likelihood of this happening?

To help answer these questions, Hersman was joined by four members of NTSB as well as two members of the Transportation Safety Board of Canada. The forum featured 21 presentations from academics, regulators, and industry thought-leaders on how to define, regulate and maintain an effective safety culture in transportation. This forum was the first NTSB had hosted on transportation safety culture in 16 years.

“Today, many organizations embrace the basic premise of safety culture and the use of data to improve the safety of their operations, with knowledge that was previously unimaginable,” Hersman said. “But saying you have a positive safety culture and living it are two different things.”

Defining safety culture

The forum opened with a discussion on the challenges of defining safety culture before safety professionals and regulators can begin to influence it.

One of the challenges is differentiating between “personal” and “process” safety, said Gudela Grote, a professor of work and organizational psychology at the Swiss Federal Institute of Technology in Zurich, Switzerland. She said personal safety refers to how safely workers perform tasks as to not injure themselves or a co-worker, while process safety refers to the safety training and knowledge to ensure that a product or process will be safe for the end user or the environment.

Personal safety tends to be “tangible” and easy to detect, while process safety is more difficult to measure and tends to be hidden – sometimes only until something goes wrong – said John Carroll, a professor of organization studies and engineering systems and co-director of the Lean Advancement Initiative at the Massachusetts Institute of Technology’s Sloan School of Management.

Carroll said process safety cannot be managed and taught the same way personal safety can, as evidenced by the Calgary, Alberta-based pipeline company, Enbridge, which was responsible for a crude oil spill in Michigan in 2010. According to Matt Nicholson, an NTSB pipeline investigator, Enbridge’s safety management system focused on the safety of field workers at pipeline sites. However, while Enbridge workers themselves may have been safe, many lacked essential safety competencies related to their work, including reporting corrosion on a pipeline or knowing when to respond to leak warnings. This contributed to the company’s failure to respond to a major leak for more than 17 hours, Nicholson said, and allowed nearly 850,000 gallons of crude oil to be pumped into the Kalamazoo River – exposing at least 320 people to a hazardous substance.

Regulating safety cultures in transportation

The research panelists also noted that it can be difficult for transportation regulatory agencies to influence safety cultures among employers.

Presenters from the Federal Railroad Administration, Federal Aviation Administration, Pipeline and Hazardous Materials Safety Administration, and others discussed how some of the most severe transportation incidents can be attributed to workers not taking their safety – or the safety of the traveling or non-traveling public – seriously. The Department of Transportation’s Safety Council recently determined that safety culture is a “top priority” across the department, said presenter Rick Kowalewski, senior policy advisor and acting chief safety officer for PHMSA. However, the council also acknowledged it would be challenging to find a way to influence safety culture through regulation without negatively affecting employers’ trust of regulators, who they may perceive as pushing too hard.

Stating that “culture is not an end in itself,” Carroll emphasized that regulators must remember it takes time for organizations to develop a safety culture.

“The way that you develop culture is by solving problems,” he said. “It’s the way that people work together, and it’s the way they achieve success. It’s difficult to just declare … that safety is our [new] No. 1 priority.”

Kowalewski suggested regulators start by being flexible. “Prescriptive regulations can inhibit flexibility that you might want for a good safety culture,” he said.

Don Osterberg, senior vice president of safety and security for Schneider National Inc., a Green Bay, WI-based provider of truckload, logistics and intermodal services, agreed with Kowalewski’s concerns. He stated that compliance reviews and litigation – although “powerful motivations” – can result in bare-minimum efforts to comply with regulations if not delivered carefully. Employers can begin to view this is as a reactive and negative agenda, he said. Instead, Osterberg recommended that regulators create incentives for safety performance by making it a “want-to” rather than a “have-to” mentality.

Stephanie Morrow, a non-transportation regulator invited to the forum and the safety culture program manager in the Office of Enforcement at the Nuclear Regulatory Commission, offered the commission’s advice on influencing a culture of safety for transportation regulators struggling with these issues. The commission simply expects – instead of mandates and enforces – that nuclear reactor operators establish and maintain safety cultures, she said. This approach maintains positive relationships with the reactor operators, she said, while also establishing baseline expectations.

Employee involvement

Speakers from transportation carriers and associations representing transportation workers also participated in the forum. Most emphasized that trust between workers and employers is crucial to maintaining a positive safety culture.

Capt. Charles Hogeman, aviation safety chair for the Air Line Pilots Association, International, said organizations with an effective safety culture have employees who take ownership in their own role for maintaining it. He recommends that aviation organizations emphasize to workers that hazard reporting must be “as fundamental as the pre-flight inspection.”

“If we can have a self-policing pride of workers out there, they can do the work of 100 inspectors,” he said.

Other employers discussed the challenges of engaging workers and maintaining safety culture.

Kevin O’Connor, vice president and general manager of rail operations for the New Jersey Transit Corp., described how workers had been afraid to speak up about a safety hazard or unsafe work practice. To improve their willingness to report – and provide the company with more crucial safety information – NJT transformed its safety culture from a discipline- and fear-based one by adapting a non-punitive reporting system developed in the aviation industry. Workers were then able to report safety violations, close calls and near misses without fear of discipline, O’Connor said, and the organization’s safety performance significantly improved.

“Folks learned that they can trust each other,” he said. “Employees no longer feared management, and management was willing to talk to employees.”

Fort Worth, TX-based American Airlines had a similar issue with employees not reporting safety problems, explained David L. Campbell, the company’s vice president of safety and operations performance. He described AA’s former culture as one in which workers began feeling others were not being held accountable for violating safety rules. To shift to a safety culture that was “just” but not overly punitive, Campbell said, the company established a list of “critical” safety behaviors all employees must follow, such as responsible decision-making, placing safety ahead of profit and reporting all safety hazards.

The future

In her closing remarks, Hersman said a key point she took away from the forum was organizations that have an effective safety culture are the ones that are always trying to improve. She praised industry speaker Capt. Pradeep Chawla, managing director for training and quality, health, safety and environment for China-based Anglo-Eastern Ship Management Ltd., for his company’s improvement despite already having an excellent safety record.

During his presentation, Chawla said that employees will perform their jobs safely only if they genuinely believe it is the right thing to do, and the organization continuously demonstrates that it considers safety above all else.

Hersman told attendees she hopes it does not take another 16 years before another forum on transportation safety culture takes place.