over competing goals.”83 For example, the Federal Railroad Administration (FRA) in 2020 issued the System Safety Program and Risk Reduction Program rule.84 One of the requirements is a passenger railroad must have a system safety program “designed so that it promotes and supports a positive railroad safety culture.”85 The Federal Highway Administration through its Zero Death initiative promotes the Safe System approach which requires a supporting safety culture.86 Also, in 2020 the Pipeline and Hazardous Materials Safety Administration (PHMSA) conducted a series of meeting with industry to discuss the benefits of an effective safety culture in response to the gas transmission final rule 84 FR 52180 and the pipeline final rule 84 FR 52260.87 Industries and regulators outside of transportation have taken similar steps. The US Nuclear Regulatory Commission in 2011 issued a Safety Culture Policy Statement which set forth the Commission's expectation that individuals and organizations establish and maintain a positive safety culture.88 The Bureau of Safety and Environmental Enforcement of the Department of the Interior which overseas portions of the oil and gas industries published their Final Safety Culture Policy Statement in 2013.89 These agencies used a mixture of mandates, voluntary compliance, and published expectations to set industry set industry baselines for safety culture develop. Yet, more often than not, serious incidents or accidents served as the catalyst for these actions. The next section discusses triggers that have promoted regulatory action.
3.2 Tragedies Often Trigger Legislation and Regulation on Safety Culture In late 2018 and early 2019, two accidents involving B737 MAX aircraft resulted in the loss of 346 passengers and crew members.90 As part of the investigation, the FAA chartered the Joint Authorities Technical Review (JATR) to review the type certification of the flight control system of the B737 MAX. The JATR published 12 recommendations which primarily focused on aircraft certification, a holistic, airplane level approach to airplane design, and the impact of design changes on pilot training and operations. Congress later passed the Aircraft Certification, Safety, and Accountability Act. These provisions were included in Public Law 116-260 and signed by the President on December 27, 2020. The Act mandates the FAA to require manufacturers that hold both a type certificate and a production certificate issued pursuant to Section 44704 of Title 49 have in place a Safety Management System (SMS) consistent with ICAO Annex 19.91 Accidents involving rotorcraft also have set regulatory focus on safety culture. On January 29, 2019, a medical helicopter crashed into terrain near Zaleski, OH. The NTSB determined that the probable cause of the accident was the operator’s “inadequate management of safety, which normalizes pilots’ and operations control specialists’ noncompliance with risk analysis procedures.”92 Specifically, NTSB noted, “the lack of a Guiding the New UAS Industry to Safety Excellence
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