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Podcast interview

The Safety Pioneers Episode 2: US National Transportation Safety Board

Find out what we can learn from major accidents of the past, the importance of sharing information and never losing sight of the fact that transport safety is an ever evolving area.

Episode transcript

Dolline Hatchett:

You might see us at the scene of a train derailment, a plane crash or in connection with a vessel sinking.

Narrator:

In this episode we hear from someone whose work puts them at the heart of the aftermath of major failures in transport safety. 

Dolline Hatchett:

When you see the investigators on the scene, that is just the beginning of our work.

Narrator:

Dolline Hatchett is the Director of the Office of Safety Recommendations with the US National Transportation Safety Board. Her role has brought her close to the consequences of many high profile accidents, such as the loss at sea of the cargo ship SS El Faro during Hurricane Joaquin in 2015. We interviewed Dolline at a networking event to find out what we can learn about making the world a safer place from the work of the NTSB.

Dolline Hatchett:

The National Transportation Safety Board is an independent federal agency and we investigate accidents in all modes of transportation so whether it’s aviation, highway, marine, pipeline, railroad. We investigate the accidents by using scientific analysis and data, talking to witnesses after it happens to get the data. Then we issue safety recommendations and those safety recommendations can go to parties such as the Federal Aviation Administration or the Coast Guard, and our main goal is to issue these recommendations, have them adopted to prevent accidents from occurring in the future.

Narrator:

Recommendations made by the NTSB about a specific accident can often highlight safety changes that will benefit other areas of transport.

Dolline Hatchett:

The National Transportation Safety Board has a division called ‘Safety Advocacy’ and we also have something called ‘the most wanted list’. The most wanted list is the top issues around safety and on which we think we can have some positive movement by working with other advocacy groups to advocate on behalf of things like fatigue when you’re driving vehicles, distractions and all sorts of things where we think we can make a positive impact to reduce deaths on the road if it’s highway, if it’s in the air and aviation, to reduce aviation complacency issues that pervade the transportation industry to ensure that people are alert and they make sure they’re doing the things they’re supposed to do to keep all modes of transportation safe.

Narrator:

An ongoing aspect of the work of the NTSB is making any safety recommendations available for countries beyond the United States.

Dolline Hatchett:

What draws me to safety is that we all benefit from it and when we share the lessons learned and we replicate that across borders we make everything safer for everyone, regardless of whether it’s a mode of transportation or if it’s in our food supply or if it’s in artificial intelligence. I think a lot of what we do is replicable, we don’t have to reinvent the wheel across borders and I think if we do more information sharing and more open dialogue about safety, we can all learn a lot from one another.

Narrator:

Even though we are rapidly seeing a rise in the role of digital systems in transport – from driverless vehicle technology to ever improving navigation systems - Dolline says one of the biggest safety challenges in transportation is still the human factor. 

Dolline Hatchett:

I think that accidents will always happen unfortunately, it’s how we respond and if there’s anything that’s preventative it’s going to be around advocation and education. Increasing awareness about those sorts of issues are those things that humans do that put us at risk of being hurt or injured when we’re in any mode of transportation. So increasing awareness on how to mitigate those factors and prevent them from happening in the future I think would be key and that’s something that we all can participate in, whether you’re a federal agency – it’s a global issue in terms of safety.

Narrator:

Sadly the human factor was identified by the NTSB as playing a major part in the loss of the Cargo Ship SS El Faro in 2015. All 33 mariners on board died when the vessel sailed into the centre of Hurricane Joaquin. During a presentation on the work of the NTSB, Dolline explained more about the circumstances surrounding this tragedy and what we can learn from them.

Dolline Hatchett:

The captain believed he was south of the hurricane, steaming eastward but he was wrong.  He was west of the storm, steaming straight into it.  The reason why he was in this predicament was because he relied on a commercial product that supplied weather information sometimes twelve hours old. He did not change course even though deck hands urged him to do so because they were using more current information. Both the crew members and the captain failed in what we call Bridge Resource Management or BRM. BRM seeks to make maximum use of all crew members, regardless of their decision making power. On board El Faro the captain was not receptive to the deck officers’ suggestions and the deck officers mitigated their speech, in other words they weren’t assertive enough with the captain to persuade him to put El Faro on a safer course.

Narrator:

As well as identifying safety limitations because of the human factor, the NTSB’s report into the SS El Faro tragedy made many other recommendations that will help to improve transport safety at sea. Here’s a clip from the soundtrack of an NTSB film on the investigation.

NTSB film/ audio clip:

The recommendations adopted by the NTSB will enhance the safety of mariners at sea, they include; improving tropical cyclone forecasting, storm advisories and weather dissemination systems, ensuring that critical machinery can operate even when the ship is rolling or severely listing in heavy seas, equipping all ships with enclosed life boats and personal locator beacons for crew members, providing electronic indicators so crew members will know if a hatch is open or closed, requiring that life-saving appliances be periodically reviewed and updated to meet future requirements.

Narrator: 

So, learning from the mistakes of the past is a crucial part of improving safety in all areas of transport for the future. This was echoed in the words of the Chairman of the NTSB, Robert Sumwalt when he summed up the recommendations of the investigation. 

Robert Sumwalt:

The SS El Faro unfortunately is no longer with us nor is the crew that she had with her on that final voyage. They’re gone but as they say certainly not forgotten. And we hope that this tragedy at sea can serve as the lighthouse to guide the safety of marine transportation.

Narrator:

…and this statement brings us on to another important aspect of the work of the NTSB - communicating their findings to the wider world so that everyone can benefit.

Dolline Hatchett:

Our safety recommendations are the business end of our work, when acted on they prevent future accidents. We can issue safety recommendations at any time during the investigation, even during the early phase of an investigation. However, in practice recommendations are commonly issued in the NTSB’s final accident report. My group is the Office of Safety Recommendations and Communications, we coordinate press conferences on the progress of the investigation, we capture appropriate images and B-rolls for video footages, coordinate and conduct press interviews on camera, we coordinate the information and services the victims so desperately need, we work in collaboration with the investigative teams to craft recommendations most likely to result in the desired action.  We gauge government sensitivities and openness to change and we work to close open recommendations favourably.

Narrator:

From communicating key messages to the wider world, sharing information across borders and different  transport areas, to embracing new technology but always keeping in mind the human factor – the work of the NTSB  highlights that Transport Safety is an ever evolving area, where perhaps the biggest challenge of all is overcoming complacency.

Dolline Hatchett:

Scratch the surface of a safety success and you’ll find a string of failures interrupted before an accident resolves. Safety is not something you attain it’s something you do. It is not a destination but a never ending journey and with all of us working together we can make all modes of transportation safer for all.

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