An ongoing safety initiative by the USC Viterbi School of Engineering and Metrolink, the regional rail commuter system serving Southern California, led to a landmark class that brought together academic experts with rail system executives and partners in a unique problem-solving format.
The class was “Rail System Safety: Safety Culture and Human Performance.” The format evolved out of months of planning discussions between Metrolink CEO John Fenton, System Safety Manager Fred Jackson, executive consultant Jim Schultz, Viterbi School Director of Professional Programs Candace House and others.
The USC teachers: from left, Tom Anthony, Najmedin Meshkati and Greg Placencia.
For the class Jackson and some 50 senior Metrolink supervisors, operators and experts assembled on the USC campus where for two days they intensively and extensively examined a series of disasters, collisions and equipment failures in systems around the country.
It was “an absolute must for anyone working in the industry,” commented Metrolink’s Rick Gallant, “and I’ve been in the industry for 41 years.”
Three Viterbi School faculty members with special academic and engineering expertise in the field led the Metrolink representatives' examinations of the record. Najmedin Meshkati, Tom Anthony and Greg Placencia focused specifically on the ways in which failure scenarios had developed out of defects in institutional safety cultures.
Safety culture is a concept that Meshkati has developed for years in the context of accidents in complex technological systems such as nuclear reactors, oil refineries, air operations centers and offshore drilling platforms.
The meeting, House emphasized, was not aimed at giving individuals certificates or degrees. It was rather designed to improve the performance of the entire institution overall.
In one of the sessions, analyzing a train crash in a Northern California system, Meshkati and Placencia used the accident scenario as the takeoff point to discuss how bad safety culture led to failure to correct errors – how “one person’s bad scheduling can become death warrants for passengers.”
Metrolink System Safety Manager Fred Jackson and Viterbi School Director of Professional Programs, Candace House worked together on “Rail System Safety: Safety Culture and Human Performance."
This discussion went on to discuss the paradoxical dual role of automation in safety culture: “making bad habits worse and good habits better.”
Metrolink's Jackson was particularly impressed by Anthony’s analysis of Safety Management Systems (SMS), a culture developed in the aviation and airline industry, but unfamiliar to him and other Metrolink personnel.
The final exercise was discussion of a June 2009 Washington, D.C. Metro crash in Fort Totten that was a bad safety culture perfect storm: an operator with persistent professional problems placed under extreme stress by a schedule that left her sleepless, a situation further complicated by communication failures, obsolescent equipment, organizational problems and lax regulatory oversight.
The 50 Metrolink representatives divided into seven teams that separately drew lessons from the National Transportation Safety Board (NTSB)’s official accident investigation report. Each team then presented its own analysis to the group.
Metrolink's Jackson was delighted by the results. “It stimulated so many thoughts,” he said – and he and his Metrolink colleagues were already talking about changes that might come out of the discussion.
One key sign, according to Jackson, was an enthusiastic consensus by Metrolink participants that improvement is possible — and will take place, he said.
Robert L. Sumwalt keynoted the Rail Safety Summit that preceded the Metrolink workshop.
House was equally pleased. “I’m proud to partner with Metrolink,” she said. So was House's supervisor, Kelly Goulis, the Viterbi School’s senior associate dean for graduate and professional programs. "We have a long history of providing educational programs to address safety issues to the aviation industry, through our Aviation Safety Program,” said Goulis. "We are thrilled to be able to apply this successful model and to develop programs in railway safety for the rail industry."
The event followed an earlier Rail Safety Summit at USC that brought together 45 participants, including representatives of all major U.S. railroads, professional railroad associations, labor organizations and government regulatory authorities.
The invited keynote speaker at this event was Robert L. Sumwalt, a board member and former vice chairman of the NTSB, whose presentation was entitled “Understanding the Critical Role of Leadership in Preventing Organizational Accidents: Lessons Learned from Investigating Major Rail Accidents.” Sumwalt, a longtime airline pilot, was no stranger to USC. With Meshkati, he co-taught a course, "Human Factors in Aviation Safety," for the USC Aviation Safety and Security Program from 2003-2006.
Safety first: top Metrorail operations staff came to the USC campus to build a safety culture.
