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Keynote Address to the 7th International IEEE Conference on Intelligent Transportation Systems.


Thank you very much, Paul, for that kind introduction .

I'm proud to be here today, and your presence here today indicates a strong commitment to improving transportation safety all over the world. During my time as Chairman of the National Transportation Safety Board I had the honor of representing the United States of America and promoting transportation safety to 33 countries around the globe. Since stepping down from the Board, I have continued this fight. Thanks to technology the world grows smaller by the day. However, those dedicated to this effort must all work together to ensure that the lessons learned from past accidents are disseminated - widely and efficiently - to guarantee that these tragedies are never repeated and to structure systems that will provide for the safe transport of humans worldwide.

* * *

One of our founding fathers, Thomas Jefferson, once said, "The care of human life and happiness is the first and only legitimate object of good government."

I'm particularly fond of that quotation because his words are as meaningful today as they were when Jefferson first spoke them - especially for all of us here today. Whether you work in government or in the private sector or in public safety, whether you live in America or anywhere else in the world, each of you is breathing life into Jefferson's words - you're putting the care of human life at the top of your to-do list every day. If we are to truly care for human life and happiness, we must first ensure every individual's safety and security.

And isn't that the great promise of intelligent transportation - making a world filled with all kinds of potential dangers a little bit safer - no - a lot safer?

With the technology available today, we owe it to the world's citizens to build safer vehicles and roadways, to make real the vision of zero fatalities, to put public safety top of mind when transportation systems are designed. Safety is not just an important issue here in the United States, but worldwide.

For instance, in Asia and South America, laws and the ministries that enforce them are having a hard time keeping up with the growth in population and changes in the economy and society that are placing more and more motorists and vehicles on the streets. Some cities with populations in the millions are lacking of some of the most basic technologies - even traffic lights.

In the U.S., when we think of the safety issues associated with transportation, we often first think of the people being transported - the airline passengers, the kids in the back seat, the tug boat operator. However, in most developing countries, the critical issue when it comes to road crash safety, for example, is not just protecting motor vehicle occupants, but the innocent bystanders, pedestrians, and bicyclists who make up the majority of injuries and fatalities in those countries. Most, if not all, of you are aware that the focus of the World Health Organization's "World Health Day" this year was road safety. Not hunger or obesity or asthma or diabetes or drug abuse, but road safety, because each year, more than 1.2 million people around the world die from injuries suffered on roadways.

While those of us who live in countries like the U.S. can take some solace in the fact that road deaths and injuries are slowly declining in our communities, the sad truth is that in less-developed countries, injuries and deaths are increasing rapidly. Of course, as we have learned here in the United States, most of these deaths and injuries - and the economic losses associated with them - can be prevented. It is imperative, then, that we take heed of the lessons we've already learned and help all nations put in place the strategies, regulations, and safety devices that we know will work. And it's not just public sector or the private sector that must solve these problems - it's something we must all do together. And we must act now. Too many people are dying, needlessly. The world is watching and depending on us.

Let me talk just a little bit about some of the developments I am tracking in intelligent transportation. Certainly, some of the most interesting advancements are helping to make us safer. We now have cars that park themselves; advanced crash-avoidance systems; GPS systems that don't let us get lost; and roadway signs that flash constantly updated information to warn us of trouble ahead and, more important, broadcast a life-saving Amber alert.

I was proud to be a part of IEEE's recent effort to develop a standard for motor vehicle 'black boxes,' and we announced the standard - the world's first - just a few weeks ago. This international protocol will help manufacturers develop event data recorders - what we know as black boxes - for cars, trucks, buses, ambulances, fire trucks, and other vehicles. The more accurate, objective data we can gather on highway crashes, the better chance we have to reduce their devastating effects. As we become better able to gather data on driver behavior, we'll be better able to assist everyone from automotive designers to accident investigators to law enforcement as they work to prevent similar accidents.

Crash-avoidance systems and motor vehicle black boxes and GPS technology are wonderful; but, unfortunately, these advancements alone are not enough to keep us - or our transport systems - safe. Today, by necessity, we must also focus on keeping us all safe from countless other dangers. For instance, we must find ways to better protect the environment - by using less gas, by easing congestion, and by saving resources through the use of more efficient systems.

And, we must protect against an increasing terrorist threat. Or, at least, we must ensure that we are able to effectively function after an attack. We can no longer just improve our vehicles or require more safety measures to protect individuals - we must protect the transportation infrastructure, and the millions of people who rely on it.

We all live in a new world with new and difficult challenges. Challenges that demand of us that we find innovative ways to integrate mobility, safety and security - and that we find ways to use, or develop, new technologies that can help us address these critical safety issues. Those of us here today must be at the forefront of that effort.

* * *

A few years ago, a book by Malcolm Gladwell called "The Tipping Point" was at the top of the bestseller lists. In his book, Gladwell discusses the timing and factors that cause new ideas or products or trends to become well-known. I think the whole notion of intelligent transportation has just about reached the tipping point - that is to say that even people who don't live and breathe intelligent transportation like we do know what you're talking about when you mention it - they are seeing it in their everyday lives and reading about it in the newspaper.

Let me share just a few examples with you because, not only do they prove my point, they also show the innovative ways we're using intelligent transportation systems to improve the safety of the world's citizens.

· Subway riders in Washington, D.C., receive instructions on how to prevent or respond to incidents such as the tragic train bombing in Madrid.

· Commuters in St. Louis, Missouri, and Oxford, Mississippi - and many other cities - go online to see which roads are congested before heading out to work.

· ITS systems in South Korea provide real-time video security on high-speed trains.

· ITS messaging systems in Windsor, Ontario, help make one of the world's busiest border crossings more efficient.

· Seattle commuters can check their bus's progress before they leave the office.

As Paul mentioned, I served as chairman of the National Transportation Safety Board under President Clinton. The NTSB is probably best known for its work in regards to aviation safety - one of my least favorite parts of the job as chairman was to direct the investigations into several major plane crashes. At its best, when the NTSB gets people working together for common goals, it is involved in creating what I call a safety culture. You, too, are part of that effort. We must build a safety culture in every nation.

But what do we mean by a safety culture? To me, it gets to the very essence of who you are and what you stand for as an individual, a company, a government, or an association. What is your driving force? What ideals do you hold to be most important? How do we develop the right habits, making safety a part of our daily routine?

One of my favorite books - many of you have also read it - is Robert Fulghum's "All I Really Need To Know I Learned In Kindergarten." He explains that as children, we developed the habit of saying please and thank you because our parents repeatedly told us to say it. Eventually, it became so engrained that we did it automatically. However, over time, some of us forget those lessons and need reminding.

That is why people and organizations and governments need overarching principles to guide their actions. Fulghum's book is not rocket science, and the point I'm making is not either. But I'll tell you this - I have seen so many basic principles forgotten in transportation, and those lapses have caused death and injuries to thousands of our fellow human beings.

So let me share with you a few of the lessons I've learned that may help you as you build a new safety culture. After all, the NTSB is known in Washington as the "national archives of what not to do." That's because our job was to uncover what went wrong to cause an accident. During my years at the Board, we took that knowledge and tried to proactively change the safety culture of some of the institutions we interacted with.

In politics, the old saying goes that "It's the economy, stupid." Well, I'd suggest that in our business, "It's the design, stupid."

As I studied the tragic state of highway safety while at NTSB, the thing that bothered me most was what was happening to our children. As a society, we like to say that we put our children first, that nothing's more important than our kids. Well, in designing cars and highways, not only did we not think of kids first, until recently, we didn't even think of them at all.

Sound like I'm overstating the case? Let me tell you why I make that statement. In the decade of the 1990s, in the United States we killed on our nation's highways more than 90,000 young people - from infant to 20 years old - and injured almost 9 million more.

It shouldn't ever have come to that. Protecting children should have been a no-brainer, but it wasn't. Over a span of about 30 years, safety advocates had to fight first for infant car seats, then for attachments for child safety seats, and then for airbags that wouldn't injure or kill children.

While I am proud that the NTSB led the way on all these safety improvements, I am bewildered that engineers and manufacturers would fail to put children first when it came to safety.

And in the case of airbags, it was not just our design engineers who failed to value a safety culture but also our political leaders. Congress established a test that required airbags to protect an unbelted 170-pound adult. The failure of this design flaw became clear during my watch at NTSB. It began when our investigators turned their attention to low-speed, low-impact accidents in which the airbag deployed and killed the child in the front seat. I was so alarmed we held a week of hearings in Washington, D.C., in 1997 and began a process that would move the automakers toward developing a second-generation airbag. We also started a national campaign to put kids in the back seat. Today, I'm happy to say that in this instance, our safety culture in manufacturing and government has advanced to the point that we have second-generation airbags in our vehicles, and many states have laws requiring kids under a certain age to ride in the back seat. Those are the kinds of lessons we've already learned here in the United States, and as a worldwide intelligent transportation community we must act on those lessons and hold global business and government accountable so people in developing countries aren't forced to learn the same lessons all over again, the hard way.

So, as we build our worldwide safety culture, always remember the first lesson I learned at NTSB: "It's the design, stupid."

The second lesson I learned is this: You must idiot-proof the design. We should never underestimate the human capacity to mess things up.

This reminds me of the tale of Napoleon's corporal. The story goes that Napoleon would always have a corporal at hand who was judged to be the stupidest man in his entire army. Every time Napoleon wanted to issue an order, he would first read it to the corporal and then have him explain what he'd just heard. Napoleon would not issue the order to his entire army until his dumb corporal could understand it. The point is that we must never underestimate the human ability to misunderstand and to fail, for accidents to happen. I don't need to remind you that 80 percent to 90 percent of all transportation tragedies are the result of human error.

Aviation maintenance documents are written at a third-grade level - not because mechanics are illiterate - but to ensure that the instructions can be easily understood. However, the same approach is not being used in regard to the computer systems designed to fly the planes. As a result, we are seeing more and more aviation accidents caused by a failure in the interface between human and computer.

Let me give you one example of an accident that involved some elements of both design failure and human failure, and a third element - organizational failure.

In 1996, a Maryland commuter train collided with an AMTRAK passenger train in suburban Maryland, killing 11 and injuring 26. The crash was blamed on operator error - the engineer on the commuter train forgot that a signal said "approach" rather than "clear" as he sped toward the AMTRAK train, and he was unable to slow his train down in time to avoid the collision.

At first glance, this is an obvious case of operator error. A human messed up - the signal said approach, not clear.

But design errors also played a big role in this tragedy. Eight of the 11 deaths came not from the collision but from the resulting fire. An NTSB summary of the event noted that "emergency egress of passengers was impeded because the passenger cars lacked readily accessible and identifiable quick-release mechanisms for the exterior doors, removable windows or kick panels in the side doors, and adequate emergency instruction signage." The design of the car did little to protect these passengers; in fact, it sealed their fate.

Where was the safety culture? To take the cause of the tragedy even further away from the poor decision by the engineer himself, let's consider the organizational failures in this case. Is a system that is dependent on an engineer remembering what he sees on a signal adequate? Clearly, this is a case where intelligent transportation systems could have prevented this tragedy from occurring. A recent increase in the number of Maryland commuter trains also played a role in the accident. When new lines were added, the potential impact on passenger safety was not addressed.

So lesson one is sound design.

Lesson two is idiot-proof design.

And lesson three in building an organizational safety culture that I'd like to share concerns the importance of collecting data. There is so much information we could collect from the roadways, cars, transit systems - the potential amount of data is simply unbelievable. Without data, how on earth can we improve the design?

I've always believed in the importance of accident recorders, or so-called 'black boxes.' The evolution of recorders is why aviation is so safe and why it is so important that this technology be integrated into our surface transportation modes. The truth is that even in the most sophisticated systems, things go wrong. The best way to be sure we stay one step ahead is with recorders, so we're able to catch incidents before they become accidents that cause fatalities.

We now have the ability to collect so much data, the question really becomes, not whether we should have data recorders or even what kinds, but how we use the information that the recorders provide. How do we share the data among all the groups who can benefit from it? How do we get public safety officials and private business and government to work together to make the most of the information? How do we protect privacy rights?

Forums like this are where these questions get asked, and where the answers begin to emerge. You can't expect any one element of the transportation system to go off in a corner and address issues as complex as standards, policy, and privacy, because indeed you are dealing with an inter-connected system of needs. You can't look to one another and point the finger expecting the person sitting next to you to solve it alone. It can't be just a private-sector problem, and I don't think you want it to become solely a government problem either. These are issues that can be solved only in a public-private-academic setting much like you've established right here.

* *

You know, one thing I always believed when I was at NTSB and as I've traveled the globe working on these issues for many years is that there needs to be a healthy tension among all the parties involved - government, business, public safety, consumer groups, academics, what have you - and that tension and the give-and-take and shared knowledge among all disciplines is what produces positive results. It is important to maintain that tension, to demand a lot from one another and get the most out of what each of us has to offer. But we need more than just tension, we need a spirit of teamwork, especially when we're talking about developing a safety culture in every corner of the world. Because many developing countries lack the resources necessary to purchase and implement many of the latest technologies, it is imperative that we work even harder in government and private industry to educate world populations on the proper operation and use of transport. We must build on the good work of the WHO and continue to take our safety messages directly to the people; we must educate the individual. And through it all, we must realize that we have common goals and interests, and that we'll succeed in building safety cultures in every nation only by learning from one another and working together.

Thank you again for inviting me here today.

Monday, October 4, 2004



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