Have you been on this Safety Culture Journey?

How did the organization assess its safety culture 

and identify weaknesses? What corrective 

actions and new initiatives did it take? How 

can it sustain a positive safety culture?

The U.S. Nuclear Regulatory Commission (NRC) 

was asked these questions many times after 

stakeholders, vendors, and others involved in 

safety regulation reviewed the safety culture case 

studies (http://www.nrc.gov/about-nrc/safetyculture/sc-outreach-edu-materials.html#sccs). In 

response to these questions, the NRC developed 

the Safety Culture Journey–a case study of an 

organization’s efforts to improve its safety culture.

Safety culture is a dynamic process that can change 

with new leadership, situations, and organizational 

conditions. Building and sustaining a positive 

safety culture that can withstand organizational 

challenges requires time, vigilance and initiative. 

An organization’s response to accidents or events 

typically includes assessment of its safety culture, 

identification of weakness, and implementation 

of corrective actions and new initiatives. An 

organization must continue to be diligent, plan 

for the future, and put goals in place to keep the 

focus on safety. The journey it takes reflects its 

commitment to safety as its highest priority.

As you read through this Safety Culture Journey, 

consider how the actions, initiatives and lessons 

learned could apply to your organization and ask 

yourself the following questions:

1. Has my organization been on this journey? 

2. What did my organization do differently?

3. What can I learn from this organization’s 

experience? 

4. How does this information increase my 

understanding of safety culture? 

5. How could I improve safety culture in my 

organization?

Safety Culture Journey A Case Study Of An Organization’s Efforts To Improve Their Safety Culture

The Washington Metropolitan 

Area Transit Authority

On Monday, June 22, 2009, the Washington 

Metropolitan Area Transit Authority 

(WMATA) Metrorail train 112 struck the 

rear of stopped Metrorail train 214 at the Fort 

Totten station. The impact caused the rear 

car of train 214 to telescope into the lead car 

of train 112. Nine people aboard train 112 

were killed and 52 people were injured.1 One 

major contributing factor to this accident 

was “WMATA’s lack of a safety culture.”1 The 

U.S. Nuclear Regulatory Commission (NRC) 

completed a safety culture case study2 on this 

Metrorail accident that appears on the NRC’s 

Web site at http://pbadupws.nrc.gov/docs/

ML1115/ML11159A220.pdf

Since the accident, WMATA has conducted 

safety culture assessments, implemented new 

initiatives and prioritized safety culture in its 

strategic plan. The journey demonstrates how 

an organization’s safety culture can contribute 

to a serious accident, how safety culture can 

be assessed and improved, and how a positive 

safety culture can be fostered and sustained 

through strategic planning and leadership 

commitment to safety as the highest priority.

Issue 1: Fall 2014
Since the Metro accident 

in 2009, there has been 

an investigation, audit, 

reports and surveys. 

These assessments 

provided WMATA with 

the information needed 

to decide what actions 

to take. Although the 

following list of reports 

is not comprehensive, it 

demonstrates WMATA’s 

safety culture journey.3

• On March 4, 2010, the Federal Transit 

Administration (FTA) issued its audit of the 

Tri-State Oversight Committee (TOC) and 

WMATA. The report highlighted key deficiencies 

in the safety and oversight programs at WMATA 

and TOC in the aftermath of the Ft. Totten 

collision, and recommended that WMATA 

fundamentally change its organization and culture.3 

• The National Transportation Safety Board (NTSB) 

investigated the accident and released its report 

on July 27, 2010. This report included the 11 

findings and 10 recommendations from the 

FTA’s 2010 audit, and it provided evidence of an 

ineffective safety culture within the organization. 

NTSB issued a total of 34 recommendations in 

connection with this accident.1 

• During 2010, the WMATA Office of the Inspector 

General (OIG) performed a control selfassessment (CSA) of employee safety. The CSA 

results indicated that employees did not believe 

WMATA provided them with a safe working 

environment because of unmitigated hazards, 

inadequate training and ineffective internal and 

external communication.3

• During July 2010, over 

9,000 WMATA employees 

completed a safety culture 

survey and the organization 

reported the results in 

October 2010. The findings 

identified numerous weaknesses in safety culture. 

Among them: Employees were concerned about 

retaliation from peers; reported safety concerns 

were not consistently addressed across Metro; and 

when safety issues were appropriately addressed, 

employees felt Metro did not close the loop with 

employees.5

•In February 2011, WMATA issued a safety 

progress report to its Board of Directors 

that included the following goal: “Many 

recommendations, one central theme-Metro must 

instill a strong, unified and pervasive safety culture 

and thereby improve the safety of our employees, 

customers and communities we serve.”6

• From September 

through October 2012, 

WMATA administered 

an Employee 

Engagement Survey to 

measure the progress in 

creating a safety culture 

and identify WMATA 

strengths and opportunities for improvement. 

The results indicated that WMATA has made 

significant progress in strengthening its safety 

culture. The most important finding was that 

employees were reporting significant progress in 

implementing Metro’s safety culture. 

• The scores of the survey indicated that employees: 

• know how to report safety issues or concerns 

• feel they have the training to do the job safely 

and can provide ideas and suggestions for 

improving safety

• assert that their direct supervisor regularly 

provides safety communication 

• report that their co-workers take safety policies 

and procedures seriously 

• believe effective action would be taken if a safety 

violation was reported

• assert they are comfortable in reporting safety 

violations and concerns7 

2 Safety Culture Journey

How Did The Organization Assess Their Safety Culture and 

Identify Weaknesses?
Initiatives Safety Culture Policy Statement Trait(s)

Metro’s Board took the lead in building a safety - first culture by 

establishing the Safety and Security Committee that provides public 

information on WMATA’s safety program activities and initiatives, safety 

performance, as well as the results of investigations into accidents and 

incidents. 

Leadership Safety Values and Actions

WMATA’s Chief Safety Officer is a direct report to the General Manager and 

Chief Executive Officer (GM/CEO) and is an active and involved member of the 

Executive Leadership Team. Since 2010, the Safety Department has doubled in 

size and increased it authority and technical capacity. The Safety Department’s 

annual budget has more than tripled since 2010 to $17.4 million. 

Leadership Safety Values and Actions

WMATA updated its Metrorail Safety Rules and Procedures Handbook 

(MSRPH), and developed a new Roadway Worker Protection (RWP) 

program. Both initiatives represent a positive change in the way WMATA 

conducts its operations and maintenance. 

Work Processes

WMATA re-established and strengthened its safety committee structure 

to ensure that safety concerns are identified at the field level, evaluated 

and resolved at the managerial level, and that conflicts and differences of 

opinion are decided at the executive level.

Problem Identification and Resolution

WMATA initiated a safety hotline that includes an anonymous, web-based 

reporting application that runs 24/7. Environment for Raising Concerns

WMATA strengthened its whistleblower policy, making it non-punitive. Environment for Raising Concerns

WMATA gave employees the right to challenge their safety on the job 

through a “Good Faith Challenge” process. Questioning Attitude

WMATA created the “Champions of Safety” program to recognize 

employees who maintain safe work practices. Personal Accountability

All WMATA executive management communications with employees have 

been reviewed to ensure that safety is included and prioritized, and is the 

first agenda item for most executive meetings and briefings.

Effective Safety Communication

WMATA’s GM/CEO conducts one-on-one monthly meetings with members 

of the Executive Leadership Team to reduce communication silos and 

promote proactive ownership of safety issues. 

Leadership Safety Values and Actions

WMATA’s Executive Safety Committee has been re-established and reviews 

WMATA’s safety performance to discuss the results of investigations into 

accidents, incidents and unusual occurrences.

Continuous Learning

In response to the 2009 accident and subsequent investigation, audits and surveys, WMATA 

implemented changes to its organization and developed new programs and policies.3,4 These 

initiatives reflect the traits of a positive safety culture as described in the NRC’s Safety 

Culture Policy Statement (SCPS). Although some initiatives could reflect several SCPS traits, 

only the most relevant trait associated with each key initiative is listed. In addition, because one trait may best 

represent several initiatives, all nine SCPS traits may not be represented below.

Issue 1: Fall 2014 3

What Corrective Actions And New Initiatives Did They Take?
In 2013, WMATA issued their 2013-2025 strategic plan, which states the following: “Continuous attention to 

improving safety culture has resulted in employees who are now highly engaged, have clarity about their mission, 

and have the authority and information to do their jobs well. Finally, the strategic plan clearly articulates that 

everyone must do their part in creating and sustaining a culture of safety and security, and affirms that safety is 

the first priority.” Goal 1 of this plan, “Build and Maintain a Premier Safety Culture and System,” reflects their 

focus on safety culture and includes the following:4

• Keep safety Metro’s first priority: Metro will 

continue its efforts to return to and keep the 

system equipment and infrastructure in good 

condition. Metro will use data-driven and 

science-based methods to allocate resources, 

use system safety practices and principles and 

environmental design to enhance safety, and 

seek to meet or exceed national safety and 

security standards for transit.

• Create a shared climate of safety: Metro will 

work with employees, riders, jurisdictional partners, and the general public to make sure that everyone does 

their part in creating and sustaining a culture of safety and security in stations, vehicles, support facilities, and 

access points. Metro will enhance its communications feedback loops to bring critical safety information to 

empowered agents quickly to prevent accidents before they happen.

• Expect the unexpected: Metro will continue to support the region’s emergency transit management and 

security readiness protocols and seek to make transit emergency protocols widely—and easily—understood. 

Metro will maintain regional evacuation capability and prepare for any event that requires wide-scale response. 

On a smaller scale, Metro will continue to improve incident response timing, planning, preparation, and 

investigation.

4 Safety Culture Journey

How Can WMATA Sustain a Positive Safety Culture?

The NRC’s Safety Culture Policy Statement (SCPS) provides the NRC’s 

expectation that individuals and organizations performing regulated activities 

establish and maintain a positive safety culture commensurate with the safety 

and security significance of their activities and the nature and complexity of 

their organizations and functions. The SCPS is not a regulation; therefore, it is 

the organization’s responsibility, as part of its safety culture program, to consider 

how to apply the SCPS to its regulated activities. 

The NRC’s SCPS defines safety culture as the core values and behaviors resulting 

from a collective commitment by leaders and individuals to emphasize safety 

over competing goals to ensure protection of people and the environment. 

Experience has shown that certain personal and organizational traits are present 

in a positive safety culture. Nine traits were included in the NRC’s SCPS, although 

additional traits may also be important in a positive safety culture. The NRC’s 

SCPS, including the nine traits of a positive safety culture, case studies, Journeys 

and Trait Talk, can be found on the NRC’s Safety Culture Website at 

http://www.nrc.gov/about-nrc/safety-culture.html. 

The NRC looks forward to continuing to provide you with information about 

an organization’s efforts to improve their safety culture. If you have a 

question or would like to make a suggestion, please contact the U.S. Nuclear 

Regulatory Commission, Office of Enforcement, Safety Culture Team, at 

external_safety_culture.resource@nrc.gov.

Source of Information:

1. Railroad Accident Report, NTSB Number RAR-10/02 

2. Safety Culture Communicator case study 1: June 

2009 Collision of Two Washington Metropolitan 

Area Transit Authority Metrorail Trains Near Fort 

Totten Station, Washington, DC

3. Rail Transit Safety Program: Safety and Maintenance 

Audit of the Washington Metropolitan Area transit 

Authority (WMATA) Final Audit Report November 

28, 2012, Federal Transit Administration, Office of 

Safety and Security.

4. MOMENTUM The Next Generation of Metro Strategic 

Plan 2013–2025

5. Safety Culture Survey Report, October 28, 2010

6. Safety Progress Report, WMATA, Safety and Security 

Committee, February 24, 2011

7. Board Action/Information Summary: Employee 

Engagement Survey, Washington Metropolitan Area 

Transit Authority, December 6, 2012

Issue 1: Fall 2014