NTSB Cites Lack of Safety Culture in Accident Investigation
The National Transportation Safety Board (NTSB) determined that a June 2009 accident involving two trains of the Washington Metropolitan Area Transit Authority (WMATA) was caused in part by the lack of a safety culture. Nine people were killed in the collision.
While the immediate cause of the accident was a track circuit module failure of the Automatic Train Control system, NTSB Chairman Deborah Hersman noted that, “The layers of safety deficiencies uncovered during the course of this investigation are troubling and reveal a systemic breakdown of safety management at all levels.”
Investigators reached numerous conclusions, including:
- Before the accident, the position of Chief Safety Officer lacked the necessary resources and authority within the organizational structure of WMATA to adequately identify and address system safety issues, ensure the distribution of safety-critical information throughout the organization, or manage the system safety program plan as required by 49 CFR Part 659;
- Shortcomings in WMATA’s internal communications, in its recognition of hazards, its assessment of risk from those hazards, and its implementation of corrective actions are all evidence of an ineffective safety culture within the organization;
- Previous attempts at non-regulatory oversight failed to compel WMATA to maintain the organizational structure necessary to ensure effective identification and communication of safety-critical information throughout its Metrorail operations.
- Elevate the safety oversight role of the WMATA Board of Directors by (1) developing a policy statement to explicitly and publicly assume the responsibility for continual oversight of system safety, (2) implementing processes to exercise oversight of system safety, including appropriate proactive performance metrics, and (3) evaluating actions taken in response to National Transportation Safety Board and Federal Transit Administration recommendations, as well as the status of open corrective action plans and the results of audits conducted by the Tri-State Oversight Committee;
- Develop and implement a non-punitive safety reporting program to collect reports from employees in all divisions within your organization, and ensure that the safety department; representatives of the operations, maintenance, and engineering departments; and representatives of labor organizations regularly review these reports and share the results of those reviews across all divisions of your organization;
- Develop a formal process by which the General Manager and managers responsible for WMATA operations, maintenance, and engineering will periodically review, in collaboration with the chief safety officer, all safety audits and open corrective action plans, and modify policy, identify and commit resources, and initiate any other action necessary to ensure that the plans are adequately addressed and closed within the required time frame.
For ship operators and other transportation professionals working within the framework of the ISM Code or similar safety management systems, much of the terminology noted above should be quite familiar. Safety culture, risk assessment, policy statement, process implementation, corrective action plans, audits, resources and authority–these are all critical to the successful implementation of a safety management system.