By John H. Reed, Chairman NTSB (1969-1976)
[Editor’s Note: This address was delivered in the 1st Annual International System Safety Symposium in July 1973. It was originally published in Volume 10 Issue 1 of Hazard Prevention (now Journal of System Safety). Additional formatting, hyperlinks, and emphasis have been added, but the text is unchanged.]
I sincerely appreciate the opportunity to meet with you today to keynote this First Annual International System Safety Symposium. It is always a pleasure to share ideas with outstanding professional organizations such as yours.
I was particularly interested in the sub-theme of this symposium “The Application Of System Safety To The Protection Of The Public.” Safety, especially of the-traveling public, is, of course, the primary concern of the National Transportation Safety Board. It is the reason for our existence.
In these remarks, I would like to highlight for you the challenges facing us in protecting the traveling public, now and in the foreseeable future. I am sure you will agree with me that we are indeed faced with a tremendous challenge if we wish to control the appalling death toll of our mobile citizenry. The use of the term “appalling” is not intended just for dramatic effect – the toll is truly appalling.
As former Transportation Secretary Volpe once noted: “Auto crashes have killed off more Americans than all our violent crimes and all the wars in our history.” We cannot let this loss continue unabated. The federal government is now attacking these losses through various forms of legislation action. However, the problems which face us cannot be solved by government alone. We need the dedicated efforts of safety specialists from all segments of the industry if we are to meet the challenge.
Before I proceed, let me briefly acquaint you with the role of the National Transportation Safety Board. The Safety Board was created in 1966 as an autonomous body within the Department of Transportation to serve essentially as the overseer of U.S. transportation safety. We have safety responsibility for all aviation transportation, and for the highway, railroad, marine and pipeline modes of transportation. The Board is composed of five members who are appointed by the President and confirmed by the Senate. We have two operating bureaus – the Bureau of Aviation Safety and the Bureau of Surface Transportation Safety, a much smaller but equally active organization. The directors of both bureaus, Mr. C.O. Miller and Mr. Henry Wakeland, as I am sure most of you know, are active members of your society. In fact, Mr. Miller is a charter member as well as a past president. I am pleased to note that both Mr. Miller and Mr. Wakeland were instrumental in the formulation of this program.
The mission of the Safety Board is twofold. We are charged with the determination of the cause or causes of all aviation accidents, and of selected surface accidents. It is also our responsibility to use this knowledge gained from our investigations to prevent recurrence of similar accidents. We do this predominantly by defining problem areas and by recommending to the appropriate parties changes which will correct the conditions which led to the accidents.
Now I would like to discuss the current safety status of our national transportation system. When measured by almost any yardstick, highway safety stands out as the number one transportation safety problem in the U.S.A. Out of a total of 60,789 transportation fatalities in 1972 (all statistics are from 1972), highway accidents accounted for 55,358 lives. In addition, the sixteen-plus million highway accidents which occurred in that year were responsible for about two-million injuries and a total property loss to the nation in excess of five-billion dollars.
The next biggest killer among our transportation modes was our railroad system, with 1,922 fatalities, followed closely by the marine mode with 1,871 total fatalities. In these two modes, 70 to 80 percent of the total fatalities were those associated with the general public – grade crossings in the case of the railroads, and recreational boaters in the marine mishaps.
The next mode, in descending order of the number of casualties, is aviation, with a total of 1,534 lives taken. Although our air carriers accounted for only 190 of these, the impact of air carrier accidents should not be minimized. Few fatal accidents create more public concern than do those involving air carrier airplanes, and the relatively few fatal air carrier accidents account for a disproportionately high percentage of the total property and equipment loss resulting ‘from all-transportation accidents. Nor is the true hazard potential reflected in these statistics, since the crash of a fully loaded Boeing 747 into a highly populated area could produce an immense death toll.
Pipeline accidents killed relatively few people last year. but here again, accident statistics can be misleading since the potential for catastrophic losses is possibly greater in the pipeline area than in any other mode.
At this point let us look at what the future holds in store. We have seen ever-increasing sophistication in all transportation systems, as evidenced by the evolution of the DC-3 into the DC-IO, and we will see a rapid growth of complex new systems such as high-speed railroad trains. The increased complexity of these systems creates greater problems in the discovery of hazards and assessment of risks, increases the cost of safety improvements, and complicates the investigation of accidents involving these vehicles.
Another problem which is challenging our ingenuity is the transportation of hazardous materials. Our expanding energy usage is resulting in the transportation of much more fuel of all types. This, of course, creates greater hazard potential for the modes involved, especially as these cargos are being concentrated into larger loads. We have seen examples of this in our supertankers, in the increased size of barge tows, and in large, widebodied jet cargo freighters.
Although our past efforts have been primarily safety oriented, our problems are no longer limited to those of saving life and limb. Social considerations now demand that we reduce the waste and pollution caused by transportation losses. In this respect, problems such as reduction or containment of oil spills from our tankships loom as a large challenge to all of us, and they will be increasingly more important in the years ahead.
Now, having reviewed the challenge facing us, what are we to do about it?
The Safety Board sees two general areas in which we believe your efforts can produce maximum results. The first of these is the need for further utilization of your knowledge and technology in all modes of transportation. Then, we need a rigorous application of system safety principles to our national transportation problems in order to direct our national safety efforts and obtain maximum benefits from our limited fund resources.
With regard to the first area, the technology and lessons learned in aviation should be applied to other forms of transportation. Those of you associated with air carrier aviation are fortunate indeed, because your accident prevention technology is highly developed compared to that of some other modes, such as highways or recreational boating. The present air carrier accident rate is evidence of continuous attention to safety.
With respect to aviation, at least, I think we can say that system safety has come of age, and that this is the time to consolidate our gains. We need to standardize and simplify techniques, and to improve the communication of practical solutions throughout the entire transportation system. This is the reason I was happy to learn of the first international gathering of system safety specialists. This is indeed a major step in that communication.
The Safety Board, since its establishment, has been anxious to disseminate new information on scientific safety methods. Our first system safety-based recommendations were made just a few months after our inception. Our two bureau directors are firmly committed to the use of this approach when it can be helpful, both in our internal accident investigation procedures and in our general safety efforts. The Board is the only agency within the Department of Transportation where transportation specialists in all modes are gathered in close association. Our success in transferring technologies among modes is one of the major forms of improvement of Department of Transportation safety approaches: We have actively transferred system safety techniques from aerospace into rapid transit, pipeline, and the marine fields; we have promoted the use of highway crash injury prevention techniques in the railroad and rapid transit fields; and we have been instrumental in applying aviation crash survival and escape requirements to the intercity bus and school bus industries.
As a result of the gains made, we believe that a strong foothold has been established for the methods which you have done so much to establish in the defense electronics and aerospace fields. We have made advances in almost all means of transportation; however, we are conscious of the fact that the national effort in some areas – notably highway safety – is still largely limited to finding remedies after the accident. This after-the-fact approach has evolved because, unfortunately, in the various means of transportation where the need is greatest – general highway operations, recreational boating, and to a lesser degree, general aviation – system safety has not yet been generally applied. System safety efforts are best applied in systems characterized by unitary control and well defined and controlled operations. In highway passenger car operations, there exists a diffusion of authority which makes changes difficult. Even in this mode, however, certain individual elements of the system safety technology such as gross hazard, failure mode and effects, and fault tree analyses might be profitably employed. However, I believe that much stronger effort will be required in order to solve the general problem of evolving our highway safety technology into a predictive, first time safe approach.
We at the Safety Board believe that, in the surface modes, system safety is closest to realization in rapid transit operations, followed by pipelines, and then by any new project starting on the drawing board. In these and in other areas, we have made recommendations which have advanced the cause of system safety. The earliest of these recommendations was that system safety concepts be applied in the Tracked Air Cushion Research Vehicle project. Then we recommended system safety application to the Washington Metro system. We also recommended that the Urban Mass Transportation Administration require submission of system safety plans as a condition for every request for capital grants and. in a special study entitled. “A Systematic Approach to Pipeline Safety,” the Board recommended the application of system safety to the entire field of pipeline safety.
Actions which we believe are highly significant have been taken on our recommendations. For example, in response to our recommendation, the Urban Mass Transportation Administration hired a system safety staff and developed a plan for implementing system safety in projects involving approximately one billion dollars of capital equipment. Also, recommendations regarding pipeline safety developed in our pipeline study are being actively taken into consideration by the Gas Piping Standards Committee of the American Society of Mechanical Engineers.
In addition to the statutorily authorized promotional aspects of our efforts, the Safety Board also has a functional role in the system safety cycle. In this cycle there is a task which is often simply defined as feedback. This, as you know, is the stage when service experience is fed back into the system to assist in identifying potential hazards and potential problem areas.
2023 Accident Facts:
- U.S. automobile fatalities peaked in 1972 around 55,000 deaths
- U.S. automobile fatalities reached their lowest since then in 2011 at 32,500
- Since 2011, U.S. fatalities are up 32%
- Worldwide, approximately 1.35 million people die on roads each year.
The Safety Board detects safety deficiencies by our accident investigation activities. and we make these known to the public and to those with safety responsibility by our recommendations.
Our accident experience also provides a valuable source of statistical information about our aviation transportation systems. Such records permit identification of significant trends by comparing the present operation of a system with its past operation. At present, we have this capability only for aviation. In the surface modes we are not only hampered by the lack of adequate data sources, but also by the fact that there is no single centralized source for storing all accident data. The Board is now striving to have established a unified, collocated accident data system which encompasses all modes.
With respect to the paucity of accident data, I should note that the NTSB is the only federal-level organization which investigates or determines cause for accidents in all modes. We are also, I might add, the only agency which investigates solely to aid accident prevention, with no interest in law enforcement proceedings. Thus, we believe that the Safety Board, by acting as the focal point for safety activities of all modes, is ideally situated to provide the impetus for system safety activities. We are a primary source of intermodal accident data. We can serve as a clearing house for safety ideas because of the public exposure we obtain by issuing reports and recommendations, by holding forums and public hearings, and by participation of our personnel in activities such as this symposium.
In summary, I believe that because of the efforts of many dedicated persons such as yourselves, transportation safety has, in some modes, reached an admirable level in this country. But we can’t rest on our laurels. We must now strive to further improve the safety levels of all modes. and we must master the problems which our rapidly advancing transportation systems will be presenting us in the future. These are problems which cross all technological, economic, sociological, and political boundaries. They are problems which will only be solved by a rigorous, total systems approach to our national transportation needs. This is a job which will require the combined efforts of government, industry, and our universities, and you ladies and gentlemen are the nucleus of the task force which must meet this challenge. I wish you well.
John H. Reed (January 5, 1921 – October 31, 2012) was the 2nd Chair of the National Transportation Safety Board and the 67th Governor of Maine. Later, Mr. Reed was twice appointed ambassador to Sri Lanka and the Maldives.
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