United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Aviation, 

Committee on Commerce, Science and 

Transportation, U.S. Senate 

NATIONAL 

TRANSPORTATION 

SAFETY BOARD 

Preliminary Observations 

on the Value of 

Comprehensive Planning, 

and Greater Use of Leading 

Practices and the Training 

Academy 

Statement of Gerald L. Dillingham, Ph.D. 

Director, Physical Infrastructure Issues 

For Release on Delivery

Expected at 9:00 a.m. EDT

Wednesday, May 24, 2006

 

GAO-06-801T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 24, 2006

NATIONAL TRANSPORTATION SAFETY 

BOARD 

Preliminary Observations on the Value of 

Comprehensive Planning, and Greater 

Use of Leading Practices and the Training 

Academy 

Highlights of GAO-06-801T, a report to 

Subcommittee on Aviation, Committee on 

Commerce, Science and Transportation 

NTSB has recently made progress in following leading management 

practices, but overall has a mixed record. For example, NTSB has improved 

its financial management by hiring a Chief Financial Officer and putting 

controls on its purchasing activities, which should address past problems 

with unapproved purchases. However, NTSB lacks a full cost accounting 

system, which would inform managers of the resources spent on individual 

investigations and provide data to balance office workload. NTSB has also 

begun to develop a performance management system that should eventually 

link each individual’s performance to the agency’s strategic goals and 

objectives. However, the performance management system will not be fully 

functional until NTSB has developed a strategic plan with results-oriented 

goals and objectives and specific strategies for achieving them, which are

lacking in the current strategic plan. Other areas, such as human capital and 

communications, partially follow leading practices. 

Extent to Which NTSB Is Following Leading Practices in Selected Management Areas 

While NTSB is accomplishing its accident investigation mission, it faces 

challenges that affect the efficiency of the report production and

recommendation close out processes. NTSB routinely takes longer than 2 

years to complete major investigations. Several factors may affect the length 

of report production, including several revisions of draft reports through 

multiple layers of the organization. In addition, the processes for federal 

transportation agencies to implement NTSB’s safety recommendations and 

for NTSB to change the status of recommendations are lengthy, paper-based, 

and labor intensive. While Department of Transportation officials have been 

working with NTSB to find acceptable means of implementing its 

recommendations, they cite the lengthy rule-making process as a challenge

to speedy implementation. 

For fiscal years 2004 and 2005, NTSB’s academy did not generate sufficient 

revenues to cover the costs of providing training. As a result, those portions 

of the academy’s costs that were not covered by the revenues from tuition 

and other sources—approximately $6.3 million in fiscal year 2004 and $3.9

million in fiscal year 2005—were offset by general appropriations to the 

agency. While NTSB has taken action to generate revenue from other 

sources, such as renting academy space for conferences, it does not have a 

marketing plan that seeks to optimize opportunities for additional revenues 

at the academy. 

The National Transportation Safety

Board (NTSB) is a relatively small

agency that plays a vital role in

transportation safety and has a

worldwide reputation for 

investigating accidents. With a staff

of about 400 and a budget of $76.7 

million in fiscal year 2006, NTSB 

investigates all civil aviation 

accidents in the United States, and

significant accidents in railroad, 

highway, marine, and pipeline; and 

issues safety recommendations to 

address issues identified during 

accident investigations. To support 

its mission, NTSB built a training 

academy, which opened in 2003 and

provides training to NTSB

investigators and others. It is 

important that NTSB use its 

resources efficiently to carry out its 

mission and maintain its 

preeminence. This testimony, based

on ongoing work for this committee, 

addresses the extent to which NTSB 

follows leading practices in selected 

management areas, addresses 

challenges in completing accident 

investigations and closing safety

recommendations, and generates 

sufficient revenues to cover costs at

its academy.

What GAO Recommends

Based on completed work to date,

GAO recommends, among other 

things, that NTSB develop a revised

strategic plan that follows 

performance-based practices, 

develop a full cost accounting 

system, and develop a marketing 

plan for the academy. NTSB agreed

with GAO’s recommendations. 

www.gao.gov/cgi-bin/getrpt?GAO-06-801T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Gerald L. 

Dillingham at (202) 512-2834 or 

dillinghamg@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

We are pleased to be here today to discuss the reauthorization of the 

National Transportation Safety Board (NTSB). NTSB is a relatively small 

agency that plays a vital role in transportation safety. With a staff of about 

400 and a budget of $76.7 million in fiscal year 2006, NTSB is charged with

investigating every civil aviation accident in the United States and 

significant accidents in the other modes—railroad, highway, marine, and 

pipeline—,determining the probable cause of these accidents and issuing 

recommendations to address safety issues identified during accident 

investigations. NTSB has gained a worldwide reputation as a preeminent 

agency in conducting transportation accident investigations. Since 1967, it

has issued 1,340 major accident investigation reports, over 130,000 brief 

accident reports, and made over 12,000 safety recommendations. To 

support its mission, NTSB built a training academy that opened in 2003 

and provides training to NTSB investigators and other transportation 

safety professionals, including those from foreign countries. It is critical 

that the agency uses its resources in an efficient manner to carry out its 

safety mission and maintain its preeminent position. For this reason, you 

asked us to conduct a comprehensive review of NTSB’s management 

functions such as strategic planning, human capital management, and 

mission-critical investigation activities. My testimony today is based on 

our ongoing work for you, and it addresses the extent to which NTSB is 

(1) following leading practices in selected management areas, (2) 

addressing challenges in completing accident investigations and closing 

safety recommendations, and (3) generating sufficient revenues to cover

costs at its academy. We will be reporting additional results of our ongoing 

work to the committee later this year. 

In summary: 

• While NTSB has recently made progress in following leading management 

practices, its overall record is mixed. For example, NTSB generally follows 

leading practices in the area of financial management. Over the last several

years, NTSB has hired a Chief Financial Officer and improved its financial 

management by putting controls on its purchasing activities, which should 

address past problems with unapproved purchases with government credit 

cards. However, NTSB lacks a full cost accounting system, which would 

inform managers of the resources spent on individual investigations and 

provide data to help assure balanced office workload. Other areas, such as

performance management, human capital, and communications, partially 

follow leading practices. For example, NTSB has begun to develop a

performance management system that should eventually link each 

Page 1 GAO-06-801T 
individual’s performance to the agency’s strategic goals and objectives. 

However, the performance management system will not be fully functional 

until NTSB has a strategic plan with results-oriented objectives and 

specific strategies for achieving them, which are lacking in the current 

strategic plan. In the area of human capital management, NTSB has 

recently developed a draft staffing plan that addresses the agency’s skills 

and competencies needs and includes strategies to increase the number of 

investigators and thereby strengthen the agency’s ability to carry out its 

transportation safety mission. However, the draft plan does not address 

organizational structure or the balance between supervisory and 

nonsupervisory positions. While NTSB has recently taken positive steps to 

improve communications from senior management to the staff—such as 

periodically sending e-mail to all staff to share information on new 

developments and policies—the agency does not regularly hold general

staff meetings or undertake anonymous surveys to obtain employee 

feedback. 

• NTSB is accomplishing its accident investigation mission, but it faces 

challenges that affect the efficiency of the report production and 

recommendation close-out processes. In terms of accomplishing its 

mission, since its inception in 1966, NTSB has investigated over 134,000 

transportation accidents, and 82 percent of its recommendations have 

been implemented, or acceptable progress toward implementation has 

been made. However, investigations are often—sometimes necessarily—

lengthy; NTSB routinely takes longer than 2 years to investigate major 

accidents. Lengthy investigations, combined with lengthy processes for 

federal agencies to regulate and industries to implement NTSB’s safety 

recommendations, can work against the goal of improving transportation 

safety. One factor that adds to the duration of investigations is that when 

new investigations are launched, inspectors are pulled from working on 

previous accidents to work on new ones. Other factors that may affect the

duration of report production include the multiple revisions of draft 

investigation reports at different levels in the organizations and resource 

issues. NTSB has recently taken several actions that may help shorten 

report development time, such as reemphasizing its policy on holding 

report development meetings to obtain early buy-in on report messages 

and holding modal directors accountable for specific issuance dates. We 

also identified practices in certain offices, such as the use of a project 

manager or deputy investigator-in-charge to handle report production, 

which may improve the efficiency of report development if used by all 

modal offices as they all are similar in what they do. The processes for 

implementing NTSB’s safety recommendations, and for NTSB to change 

the status of recommendations are also lengthy and labor intensive. As a 

result, unsafe conditions may continue to exist until federal transportation 

Page 2 GAO-06-801T 
agencies, and ultimately, transportation industries, fully implement the 

recommendations, and the extended period it takes to change the status of 

recommendations ties up NTSB’s scarce resources. As of May 2006, 305 of

the 852 open recommendations have been in open status for 5 years or 

more. While Department of Transportation (DOT) officials have been 

working with NTSB to find acceptable means of implementing its 

recommendations, they cite the lengthy rule-making process as a challenge

to speedy implementation. In addition, the process that NTSB uses to 

change the status of safety recommendations is paper-based, labor 

intensive, and relies on a series of sequential reviews that can take months 

to complete. As a result, resources within NTSB are inefficiently used and 

DOT agency officials told us they remain unaware whether their response 

has been accepted or not accepted.

• For fiscal years 2004 and 2005, NTSB’s academy did not generate sufficient 

revenues to cover the costs of providing training. As a result, those 

portions of the academy’s costs that were not covered by the revenues 

from tuition and other sources—approximately $6.3 million in fiscal year 

2004 and $3.9 million in fiscal year 2005—were offset by general 

appropriations to the agency. Although there is no statutory requirement 

that revenues from NTSB’s academy generate sufficient revenues to cover

the costs, NTSB was encouraged in the Senate report accompanying the 

Fiscal Year 2006 DOT Appropriations Act to be more aggressive in 

imposing and collecting fees to cover the costs. While NTSB has taken 

action to generate revenue from other sources, such as renting academy 

space for conferences, it does not have a business plan that seeks to 

optimize opportunities for additional revenues at the academy. 

Additionally, NTSB is missing opportunities to find other uses for academy 

space. For example, during fiscal year 2005, less than 10 percent of the 

total classroom space was used. About 14 percent of the academy students 

in fiscal year 2005 were NTSB employees. However, in 2006, NTSB 

employees are scheduled to take 97 percent of their requested training 

from sources other than the academy, such as DOT’s Transportation 

Safety Institute. The academy is not utilized more by NTSB staff, in part, 

because the agency has not developed a core curriculum for its staff, 

which it could then offer at the academy. Furthermore, many academy 

courses are similar to those taught elsewhere, which may affect the 

agency’s ability to attract non-NTSB students. 

Page 3 GAO-06-801T 
NTSB was established in 1966 as an independent government agency

located within the newly formed DOT.1

 In 1974, Congress made NTSB 

completely separate from DOT.2

 NTSB’s principal responsibility is to 

promote transportation safety by investigating transportation accidents, 

determining the probable cause, and issuing recommendations to address 

safety issues identified during accident investigations. Unlike other 

transportation agencies, such as the Federal Aviation Administration 

(FAA), NTSB does not have the authority to promulgate regulations to 

promote safety, but makes recommendations in its accident reports and 

safety studies3

 to other agencies that have such regulatory authority. The 

federal agencies that receive NTSB recommendations include the DOT’s 

FAA, Federal Highway Administration (FHWA), Federal Motor Carrier 

Safety Administration (FMCSA), Federal Railroad Administration (FRA), 

Federal Transit Administration (FTA), National Highway Traffic Safety

Administration (NHTSA), Pipeline and Hazardous Materials Safety 

Administration (PHMSA), and the U.S. Coast Guard. NTSB also makes 

recommendations to others, such as state transportation authorities and 

industries. As figure 1 indicates, NTSB has varying degrees of flexibility in 

its statutory mandate, as it pertains to initiating an investigation. By 

statute, NTSB has limited discretion in deciding which aviation accidents 

to investigate and the greatest amount of discretion to investigate highway 

accidents. 

Background 

 1

Department of Transportation Act, P.L. 89-670, Oct. 15, 1966.

2

Independent Safety Board Act, P.L. 93-633, Title III, 1974. 

3

NTSB conducts safety studies as a result of identifying safety concerns rather than as a

result of specific accidents. 

Page 4 GAO-06-801T 
Figure 1: NTSB’s Investigative Policy by Mode

NTSB is comprised of a five member board—a chairman, vice chairman, 

and three members—appointed by the President with the advice and 

consent of the Senate.

4

 The chairman is NTSB’s chief executive and 

 4

Not more than three members may be appointed from the same political party. At least 

three members are appointed on the basis of technical qualification, professional standing, 

and demonstrated knowledge in accident reconstruction, safety engineering, human 

factors, transportation safety, or transportation regulation. 

Page 5 GAO-06-801T 
administrative officer. As of March 2006, the board was supported by a 

staff of 396, which includes 210 investigators assigned to four modal 

offices—aviation; highway; marine; and rail, pipeline, hazardous materials. 

(See fig. 2.) The agency is headquartered in Washington, D.C., and 

maintains 10 field offices nationwide and a training academy in Ashburn, 

Virginia, in suburban Washington, D.C. In recent years, the agency has 

shrunk in size due to budget constraints, which it has largely dealt with by

using attrition to downsize the staff. In 2003, NTSB had 438 full time 

employees compared with the current level of 396. During the same 

period, the number of full-time investigators decreased from 234 to 210. 

NTSB’s modal offices vary in size, with the aviation office having 125 

employees; the rail, pipeline, and hazardous materials office having 38; the 

highway office having 30; and the marine office having 16 employees as of

May 2006. An additional 42 employees work in the Office of Research and

Engineering, which provides technical, laboratory, analytical, and 

engineering support for the modal investigation offices. For example, it is

responsible for interpreting data recorders, creating accident computer 

simulations, and publishing general safety studies. NTSB’s budget 

increased from $62.9 million in fiscal year 2001 to $76.7 million in fiscal 

year 2006, or about 22 percent. After adjusting for inflation, this represents 

an increase of about 9 percent. The President has requested $79.6 million 

for NTSB in fiscal year 2007. 

Page 6 GAO-06-801T 
Figure 2: NTSB’s Organization 

Since 1966, NTSB has investigated over 124,000 aviation accidents and 

over 10,000 surface transportation accidents. Figure 3 shows the total 

number of aviation investigations that NTSB has undertaken over the past 

6 years and the degree to which NTSB was involved in the investigations. 

NTSB lacks the resources to conduct on-scene investigations of all 

aviation accidents. As a result, for general aviation accidents, NTSB 

delegates the gathering of on-scene information to FAA investigators, as 

allowed by statute.5

 In these limited investigations, FAA sends the accident 

information to NTSB, and NTSB then determines a probable cause for the 

accident. In addition, NTSB participates in the investigations of foreign 

aviation accidents in conformance with Annex 13 of the International Civil 

Aeronautics Organization Treaty. These investigations involve a U.S. 

carrier or U.S.-built aircraft, or occur at the request of a foreign 

government. NTSB aviation investigators told us that there is often 

significant value in participating in such investigations; the findings often

have safety implications for U.S. carriers, since most foreign airlines use 

 5

49 U.S.C Sec. 1132(c). 

Page 7 GAO-06-801T 
U.S.-made aircraft, engines, and other parts and multiple foreign air 

carriers operate within the United States. 

Page 8 GAO-06-801T 
Figure 3: NTSB Involvement in Aviation Accidents, Fiscal Years 2000-2005 

Note: Limited investigations are those in which NTSB delegates the gathering of on-scene information 

to FAA inspectors. 

Page 9 GAO-06-801T 
Through our work government wide we have identified a number of key 

functional areas and leading practices in areas that are important for 

managing an agency. This testimony focuses on NTSB’s performance in 

five key functional areas—strategic planning, performance management, 

human capital, financial management, and communications—and how 

NTSB’s practices compare to leading practices in those areas. As 

illustrated in figure 4, NTSB generally is following leading practices in 

financial management, only minimally following leading practices in 

strategic planning, and has mixed results for the other functions. Much of 

NTSB’s progress toward following leading practices is due to recent 

management initiatives. The report we will be issuing later this year will 

provide additional information on NTSB’s performance relative to these 

five management functions, as well as information technology, acquisition 

management (including the agency’s use of contracting), knowledge 

management, and capital decisionmaking. 

NTSB Has Made 

Recent Progress in 

Following Leading 

Management 

Practices, But Overall 

Record Remains 

Mixed 

Figure 4: Extent to Which NTSB Is Following Leading Practices in Selected

Management Areas

Page 10 GAO-06-801T 
The Congress and the President have encouraged better management of 

federal agencies by means such as results-oriented strategic planning, but

NTSB’s strategic plan generally does not follow performance-based 

practices. Without effective short- and long-term planning, federal 

agencies risk delivering programs and services that may or may not meet 

the nation’s most critical needs. The Government Performance and Results 

Act of 1993 (GPRA)6

 and guidance contained in the Office of Management 

and Budget’s (OMB) Circular A-11, provide performance-based strategic 

planning guidelines. GPRA was intended to achieve several broad 

purposes, including improving federal program effectiveness, 

accountability, and service delivery, and enhancing congressional decision

making by providing more objective information on program performance. 

GPRA requires federal agencies to develop strategic plans in which they 

define their missions, establish results-oriented goals, and identify the 

strategies that will be needed to achieve those goals. For instance, GPRA 

requires strategic plan updates at least every 3 years, and requires that 

agencies set objectives and goals that are specific outcomes that the 

organization wishes to accomplish (called outcome-related objectives). 

NTSB’s Strategic Plan 

Lacks Certain 

Performance-Based 

Elements and Performance 

Management Plans Closely 

Follow Leading Practices 

but are not Fully 

Functional 

To its credit, in December 2005, NTSB issued a strategic plan for the years

2006 through 2010, which was the first time the agency had a strategic plan

in 6 years. In developing that plan, senior agency officials told us that they

modeled their plan on examples from other federal agencies with similar 

structure and mission, such as the Federal Communications Commission. 

We compared NTSB’s strategic plan to selected elements required by 

GPRA. (See fig. 5.) 

 6

Pub. L. No. 103-62. 

Page 11 GAO-06-801T 
Figure 5: Extent to Which NTSB’s Strategic Plan Follows GPRA Elements 

GPRA elements Follows GPRA elements

Source: GAO’s analysis of NTSB data.

Mission statement 

General goals and objectives

Approaches or strategies to achieve goals and objectives

Relationship between general goals and annual goals

External factors

Program evaluations

Five year time frame

Follows GPRA elements

Stakeholder involvement

While NTSB’s 5-year strategic plan has a mission statement, four general 

goals and related objectives, and mentions key factors, such as declining

resources, that could affect the agency’s ability to achieve those goals, the 

plan lacks a number of key elements—including information about the 

operational processes; skills and technology; and the human, capital, and 

information resources—required to meet the goals and objectives. In 

addition, the goals and objectives lack sufficient specificity to know 

whether they have been achieved. One goal states “NTSB will maintain its 

response capacity for investigation of accidents and increase its analysis 

of incidents.” An objective of that goal is to “continuously assess the most 

robust and efficient approaches to accident investigation.” Although such 

a goal is important for the safety of the transportation industry, this and 

the other three goals and related objectives are not measurable. As a 

result, it will be difficult for NTSB and others to determine if the goals 

have been achieved. 

In addition, the plan lacks specific strategies for achieving those goals. 

According to GPRA, the strategies should include a description of the 

operational processes, skills and technology, and the resources required to 

meet the goals and objectives. Since NTSB’s strategic plan lacks such a 

description, it does not align staffing, training, or other human resource 

management to strategic goals. That is, the plan does not explicitly explain 

how NTSB will use its resources to meet its mission and goals. While the 

Page 12 GAO-06-801T 
plan explains that each program office has its own objectives linked to the

agency’s goals and objectives, the plan contains no information to 

understand how each office contributes to those goals and objectives. In 

addition, NTSB’s strategic plan does not describe how the performance 

goals contained in the annual performance plan are related to the general 

goals and objectives in the strategic plan, as required by GPRA. 

GPRA also requires federal agencies to provide a description in their 

strategic plans of the program evaluations used in establishing or revising 

general goals and objectives and a schedule for future program evaluation. 

NTSB’s strategic plan lacks this information. As a result of having no 

program evaluations, it is unclear how or whether NTSB reviews its efforts 

to identify strengths it can maximize and weaknesses it should address. In 

developing a strategic plan, GRPA requires agencies to consult with 

Congress and other stakeholders. We have previously reported that other 

stakeholders of federal agencies include state and local governments, 

other federal agencies, interest groups, and agency employees. NTSB’s 

strategic plan does not mention consultation with any stakeholders in its 

development. Furthermore, board members and agency staff told us that 

they had no involvement in the development of the strategic plan. Some 

current and past board members additionally stated that they believed that 

their involvement would be beneficial in providing a strategic vision for 

the agency. NTSB’s senior management told us they expect to revise the 

strategic plan in the near future and contacted us regarding assistance to 

develop a more comprehensive, results-oriented plan as part of this study. 

NTSB has begun to develop a performance management system that 

should eventually link each individual’s performance throughout the 

agency to the agency’s strategic goals and objectives. We have reported 

that performance management systems are crucial for agencies because if

developed properly they allow employees to make meaningful

contributions that directly contribute to agency goals.7

 NTSB has 

developed a comprehensive performance management plan for Senior 

Executive Series (SES) employees that links individual performance to 

strategic goals. Furthermore, the plan states that NTSB will link 

performance management with the agency’s results-oriented goals and set 

and communicate individual and organizational goals and expectations. 

 7

GAO, Results Oriented Cultures: Creating a Clear Linkage between Individual

Performance and Organizational Success, GAO-03-488 (Washington, D.C.: March 14, 

2003). 

Page 13 GAO-06-801T 
This plan establishes individual performance criteria and the appraisal 

process. The appraisal process defines performance standards and 

explains performance elements that determine individual ratings. Because

NTSB recognizes in this plan the importance of aligning organizational 

performance with individual performance and contributions to the 

agency’s mission, the performance management plan is a step in the right 

direction. 

Along with the SES plan, NTSB issued in August 2005 a performance plan

for its overall workforce, which includes some elements of linking 

individual performance to organizational goals. However, without having 

results-oriented goals in the strategic plan itself, neither of the two 

performance management plans are fully functional. That is, until NTSB’s 

goals are more fully articulated in the strategic plan, it will be impossible 

for staff to know whether their performance contributes to meeting those 

goals. As with the strategic plan, NTSB staff was not involved in the 

development of the performance plan, and there was no mechanism for 

employee feedback after the plan was initially developed. Employee 

involvement provides greater assurance that policies are accepted and

implemented because employees had a stake in their development. 

NTSB’s Staffing Plan Is a 

Step in the Right Direction, 

but the Organizational 

Structure Has Not Been 

Reviewed 

NTSB developed a draft agencywide staffing plan in December 2005 that 

follows several leading practices but lacks a workforce deployment 

strategy that considers the organizational structure and its balance of 

supervisory and non-supervisory positions. Existing strategic workforce 

planning tools and models suggest that certain principles should be 

followed in strategic workforce planning, such as determining the agency’s 

skills and competencies needs; involving stakeholders (e.g., management 

and employees) in the planning process; and developing succession plans 

to anticipate upcoming employee retirement and workforce shifts.8

Further, in workforce deployment, it is important to have human capital 

strategies to avoid excess organizational layers and to properly balance 

supervisory and nonsupervisory positions.9

 NTSB’s draft staffing plan 

addresses the agency’s skills and competencies needs and includes 

strategies to deal with workforce shifts. For example, the staffing plan 

 8

GAO, A Model of Strategic Human Capital Management, GAO-02-373SP (Washington,

D.C.: March. 15, 2002) and GAO, Human Capital: Key Principles for Effective Strategic 

Workforce Planning, GAO-04-39 (Washington, D.C.: December 11, 2003). 

9

GAO, Executive Agency Management Diagnostic Survey (draft). 

Page 14 GAO-06-801T 
proposes to increase the number of investigative staff by 21, which will 

help with the agency’s resource needs. In addition, while some 

stakeholders (i.e., managers) were involved in the planning process, 

employees were not included. As we mentioned previously in this 

testimony, employee input provides greater assurance that policies are 

accepted and implemented because employees have a stake in their 

development. 

To develop the staffing plan, each modal office director submitted to 

NTSB’s Managing Director an ideal staff size for his office, including 

additional slots for investigators. The increase in investigative staff is 

consistent with requests by modal offices to enhance their ability to 

conduct their investigative mission. Managers told us that current staffing 

constraints inhibited their ability to conduct more accident investigations 

and indicated an increase in staff would be helpful. For example, directors 

of the highway and rail/pipeline offices told us they could not initiate 

investigations on more than two accidents at a time because they lacked 

sufficient investigative staff to do more.10 The modal office directors’ 

request for staff resulted in a total agency allotment of 455 full time 

equivalents (FTEs) plus 20 co-op positions. The Managing Director 

reduced this number to 404, which corresponds to NTSB’s current funding 

level of 395, allowing for attrition and turnover. The Managing Director’s 

allocation resulted in a proposed increase of 21 investigators agencywide 

and a proposed reduction of certain staff positions to accommodate the 

increase in investigators. This increase in investigative staff is consistent 

with a recommendation by RAND Corporation, which evaluated NTSB’s 

accident investigation process and workload in 1999.11 To help implement 

the realignment, senior managers told us that they would like to transition 

some existing administrative and support staff with appropriate 

background and training into investigator roles where possible. The draft 

plan set a target date of May 2006 to begin creating developmental 

opportunities for staff to transition to investigative roles and to develop

reduction strategies for staff that fall outside the staffing plan. 

 10Each investigative team initially consists of at least one investigator-in-charge and other 

technical support investigator positions based on the complexity of the accident. 

11RAND Institute for Civil Justice, Safety in the Skies: Personnel and Parties in NTSB 

Accident Investigations (Santa Monica, CA.: 2000). 

Page 15 GAO-06-801T 
Training is another key area of human capital management. It is important 

for agencies to develop a strategic approach to training its workforce, 

which involves establishing training priorities and leveraging investments 

in training to achieve agency results; identifying specific training initiatives 

that improve individual and agency performance; ensuring effective and 

efficient delivery of training opportunities in an environment that supports 

learning and change; and demonstrating how training efforts contribute to 

improved performance and results.12 NTSB has not developed a strategic 

training plan, nor has it identified the core competencies needed to 

support its mission and a curriculum to develop those competencies. As a 

result of not having a core curriculum that is linked in this manner, NTSB 

lacks assurance that the courses that staff take provide the technical 

knowledge and skills necessary for them to be competent for the type of

work they perform. 

NTSB Lacks a Strategic 

Approach to Training Staff 

Financial Management Is 

Improved, but NTSB Lacks 

a Full Cost Accounting 

System 

Sound financial management is crucial for responsible stewardship of 

federal resources.13 In recent years, NTSB has made significant progress in 

improving its financial management. In March 2001, NTSB hired a Chief 

Financial Officer who has emphasized the importance of sound financial

management based on best practices. Similar to private sector companies, 

government agencies are required to report their financial condition in 

publicly available financial statements. As a result of actions taken by

NTSB, the agency received an unqualified or “clean” opinion from 

independent auditors on its financial statements for the fiscal years ending

September 30 for the years 2003, 2004, and 2005. The audit report 

concluded that NTSB’s financial statements presented fairly, in all material 

respects, the financial position, net cost, changes in net position, 

budgetary resources, and financing in conformity with generally accepted 

accounting principles for the three years. NTSB has also improved its 

purchasing and contracting activities after identifying problems in those 

areas in 1999. In 2001, DOT’s Office of Inspector General (DOTIG) 

reviewed the agency’s contracting and procurement activities and 

recommended that NTSB institute accountability and controls in its 

purchase card program as well as other purchasing activities. As a result 

 12GAO, Human Capital: A Guide for Assessing Strategic Training and Development

Efforts in the Federal Government, GAO-04-546G (Washington, D.C.: March 1, 2004). 

13GAO, Executive Guide: Creating Value through World-class Financial Management, 

GAO/AIMD-00-134 (Washington, D.C.: April 2000). 

Page 16 GAO-06-801T 
of this and another DOTIG audit,14 NTSB has taken a number of initiatives

to improve its purchasing and contracting activities. For example, NTSB 

restructured its purchase card system and guidelines to address problems, 

such as unrestrained and unapproved purchases on government credit 

cards. NTSB hired a manager of the contracting function to manage the 

agency’s acquisition function and implement the DOTIG 

recommendations. In our full report, we will analyze some of these 

initiatives in more detail. 

In 2000, RAND recommended that NTSB develop systems that would 

allow the agency to better manage its resources by permitting full-cost 

accounting15 of all agency activities.16 To accomplish this, RAND 

recommended putting in place a timekeeping system, in which individual

project numbers were assigned to each investigation and support activities 

such as training. With this information, project managers could better 

understand how staff resources were utilized and project workload could 

be actively monitored by the Managing Director. NTSB has begun to 

implement this recommendation by upgrading a software system in 

November 2005 that tracks employee annual leave and sick leave. 

However, the system is not being fully utilized to track the number of 

hours staff spend on each investigation. Also, this system is not used to 

track time staff spend in training or at conferences. As a result, RAND’s 

previous conclusion that “NTSB managers have little information they can 

use to plan the utilization of staff resources or manage staff workloads 

properly” remains current. 

 14DOTIG, Audit of the Purchase Card Program, FI-2005-072 (Washington, D.C.: Aug. 23, 

2005) and Report on Financial Management Practices and Internal Controls, FI-2003-004 

(Washington, D.C.: Dec. 11, 2002). 

15Cost accounting involves the accumulation and analysis of financial and nonfinancial 

data, resulting in the allocation of costs to organizational pursuits such as performance

goals, programs, activities, and outputs. Nonfinancial data measure the occurrences of 

activities and can include, for example, the number of hours worked. 

16RAND Institute for Civil Justice, 2000. 

Page 17 GAO-06-801T 
We have identified useful practices related to managing employees that 

include seeking and monitoring employee attitudes, encouraging two-way 

communication between employees and management, and incorporating 

employee feedback into new policies and procedures.17 In response to 

issues raised by NTSB employees in a governmentwide survey conducted 

by OPM in 2004, NTSB’s senior management made changes to improve the

way it is communicating information to staff. For example, the Managing

Director periodically sends “management advisory” e-mail to all staff that

share information such as policy changes or new developments at the 

agency. However, we found no formal processes that encouraged two-way 

communication, such as town hall meetings, regular staff meetings, or 

anonymous employee surveys; or incorporated employee feedback into 

policy-making. 

Communications from 

Senior Management to 

Staff have Increased and 

Communications Among 

Offices is Generally In 

Place, but Upwards 

Communications 

Mechanisms Are Lacking 

The 23 investigators and writer editors with whom we spoke had mixed 

views on the effectiveness of communications within the agency.18 The 

four investigators from one modal office that we spoke with told us that 

they are pleased to now hear about policy changes at the agency, but said 

that there is too much reliance on the Internet for these communications. 

They also told us that although they believe the increased communications 

are positive, they found it difficult to find the time to read the material and

still conduct their regular investigative duties. The four investigators that 

we spoke with from another modal office agreed that staff meetings occur

infrequently and that they do not receive information on new policies from 

their managers. Further, they said that new policies or agency issues are 

not discussed with staff prior to issuance, and there was no formal 

mechanism to provide feedback during the policies’ development. In the 

past, regular formal meetings occurred between union leadership and 

senior NTSB management, which allowed for such input, but that practice 

ceased. Although formal communication processes from the staff level to 

management are lacking, informal e-mail communications do take place 

occasionally between staff and senior management. 

 17GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers and

Organizational Transformations, GAO-03-669 (Washington, D.C.: July 2, 2003). 

18We randomly selected 15 investigators and 8 writer editors evenly across the 4 modal 

offices and interviewed them to obtain their views on NTSB’s processes. The views

represent the particular individuals and are not representative of all NTSB investigators

and writer editors. 

Page 18 GAO-06-801T 
Communication and collaboration across offices at all levels can improve

an agency’s ability to carry out its mission by providing opportunities to 

share best practices and helping to ensure that any needed input is 

provided in a timely manner. We found that communication and 

collaboration between the Research and Engineering office and the modal 

offices appears to be regular. This is shown by the inclusion of Research 

and Engineering staff as core members of major investigative teams. Also, 

our review of workload in the Research and Engineering office shows a 

large number of projects that support all modes, and a Research and 

Engineering manager told us that his office frequently interacts with 

investigative staff. 

In contrast, NTSB lacks processes that would allow investigators and 

writer editors to communicate across the modal offices regarding the 

investigative process and other issues, according to staff we spoke to. The 

four investigators that we spoke with from one modal office told us that 

they are isolated from the rest of the agency and that lessons learned are

not shared across offices. The investigators from another modal office told

us that they are on permanent teams that share the same priorities in 

completing accident analysis, which enhances communication and 

teamwork in the office. In addition, in previous years, all writer editors 

were located in one group and reported directly to the Managing Director. 

Now, each modal office has its own staff of writers and editors. While they 

have retained personal working relationships from when they were 

located in the same office, four of the eight writer editors we spoke with 

said that they no longer share information with each other regularly.19 As a 

result, efficiencies and lessons learned that investigators and writer editor 

staff in one office might develop might not be shared with other offices. 

However, NTSB officials pointed out that every 6 months writer editors 

have the opportunity to meet with the publications specialist for training 

and to exchange information. 

 19The writer editors held a conference in February 2004.

Page 19 GAO-06-801T 
While NTSB is accomplishing its accident investigation mission, it faces 

challenges that affect the efficiency of the report production and 

recommendation close-out processes. In terms of accomplishing its 

mission, since its inception, NTSB has investigated over 134,000 

transportation accidents. Eighty-two percent of its recommendations have

been “accepted,” a term NTSB uses to include recommendations that 

recipients have said they would implement as well as those that have

already been implemented. Figure 6 shows that highway recommendations 

have the highest acceptance rate and marine recommendations have the

lowest. 

NTSB Is

Accomplishing Its 

Accident Investigation 

Mission, but 

Opportunities Exist to 

Gain Efficiencies 

Figure 6: Recommendations and Acceptance Rates of Recommendations by Mode, 1967-May 2006 

Page 20 GAO-06-801T 
NTSB Investigations Are 

Often Lengthy, in Part 

Because Investigators 

Must Launch New 

Investigations Before 

Completing Ongoing 

Investigations 

Investigations have four phases—the “launch,” fact finding, analysis, and 

report production. After a report is issued and recommendations made, 

the progress of implementing the recommendations is tracked during a 

fifth close-out phase. Figure 7 describes these phases. 

Figure 7: Components of an NTSB Investigation and Recommendation Close Out 

a

IIC is the “investigator in charge.” 

b

A group chairman is a technical specialist who is responsible for developing the facts and analysis 

for a particular area of an investigation. 

Investigations are often lengthy and sometimes necessarily so. NTSB 

routinely takes longer than 2 years to complete major aviation 

investigations. For example, the total time to complete major aviation 

investigations has increased from an average of about 1.25 years in 1996 to 

an average of almost 3.5 years in 2006. (See fig. 8.) In 2004, NTSB 

contracted with Booz Allen Hamilton to examine and make 

recommendations to improve the report development process and the 

Page 21 GAO-06-801T 
recommendation close-out process. Booz Allen Hamilton20 reported that 

the average time to complete major investigations across all the modes 

was either 1.8 months or 1.9 months for 4 out of 5 years.21 Lengthy 

investigations, combined with lengthy processes for federal agencies to 

develop regulations based on those recommendations and industries to 

implement the recommendations can work against the goal of improving 

transportation safety. 

Figure 8: Average Duration of Major Aviation Investigations, 1996-2006

Note: Several complex, lengthy investigations were completed in 2000, including the crash of TWA 

flight 800, which took over 4 years to complete. 

 20 Booz Allen Hamilton, NTSB Organizational Process and Efficiency Study (Washington, 

D.C.: Aug. 12, 2004). 

21In fiscal years 1999 and 2002, Booz Allen Hamilton found that the average time to 

complete a major investigation was 1.8 years; in fiscal years 2001 and 2003, the average

time was 1.9 years; in fiscal year 2000 the average was 2.4, mainly due to several lengthy 

aviation investigations that took over 4 years to complete. 

Page 22 GAO-06-801T 
One factor that adds to the duration of investigations is that when new 

investigations are launched, investigators are pulled from working on 

previous accidents to work on new ones. For example, when a major 

commercial aviation accident occurs, an NTSB “go team” is dispatched 

from Washington D.C., usually within hours of notification of the accident. 

In such cases, the team members must leave the investigations they had 

been working on to begin fact-finding on the new accident. In the cases of 

rail and highway accidents, NTSB investigators must also arrive quickly on

scene to gather information because the accident scenes will be cleared 

quickly so that traffic can resume. The manager of one department told us 

that all of his ongoing reports would be delayed by 2 months if a sudden 

launch were to occur. The number of major investigations that are ongoing

for each mode is shown in figure 9. 

Figure 9: Number of Ongoing Major Investigations by Mode, As of February 2006 

Note: This table does not include limited aviation investigations, in which FAA has the primary factfinding role. 

Page 23 GAO-06-801T 
Writing and Report 

Production Is a Bottleneck 

in the Process 

Another reason for the expansive time frame for accident investigations is 

that reports receive multiple revisions at different levels in the

organization, including the office directors and the Managing Director’s 

office, prior to going to the board members for final voting and approval of 

the draft report. An investigation report typically goes through the 

following reviews: the modal office, the Office of Research and 

Engineering, the Executive Secretariat, the Office of Safety

Recommendations, the Office of General Counsel, the deputy managing 

director, the Managing Director’s office, and each board member and the 

Chairman. For any review, there may be multiple iterations. Eleven 

investigators and 6 writer editors told us that the review process often 

results in improved clarity for report recommendations.22 However, 

investigators and writer editors also told us that they believe the levels of 

management review and approval for written products are excessive. All 

eight writer editors agreed that the reviews by the Executive Secretariat’s

office, which services a quality assurance function, was a bottleneck for 

getting products approved. They told us that it is common for 

correspondence and other products to be delayed in this office for 1 week 

or more, which they viewed as excessive. While it may be a reasonable 

expectation for short products, such as correspondence, to be reviewed in

less than a week, that expectation may not be reasonable for reports. Booz 

Allen Hamilton confirmed multiple iterations of review as the draft was 

routed through numerous offices. On average Booz Allen Hamilton found 

that there were 7 levels of reviews within a given modal office that 

resulted in an average of 28 separate reviews. A senior NTSB official 

stated that the many levels of review were needed to get the appropriate 

perspectives from relevant offices that had been involved in report 

development, such as the Research and Engineering Office and Safety 

Recommendation Office. The official also noted that the process can be 

streamlined on a case-by-case basis in which the usual process of 

sequential reviews is replaced with concurrent reviews. The NTSB official 

told us that there are no explicit criteria for determining when the 

streamlined process could be used. 

NTSB staff with whom we spoke reported that resource issues contributed 

to other bottlenecks. For example, four writer editors pointed out that 

NTSB has only one final layout and typesetting person. As of May 2006, the 

final layout process had a backlog of approximately 10 reports that have 

 22Booz Allen Hamilton, however, found that the logic and rationale for changes made 

during the review process were not transparent. 

Page 24 GAO-06-801T 
been approved for issuance at board meetings but have not yet been 

published. NTSB adopts about 2 reports a month and issues on average 4 

reports a month. In addition, some investigators have the perception that 

the workload of writer editors is another bottleneck. For example, one 

investigator told us that he submitted draft reports to the senior writer 

editor in September 2005, and as of April 2006, no additional writing had 

been done on his project. Writer editors from each modal office told us 

they typically worked on five or more products at one time. 

Certain Agency Practices 

May Help Shorten Report 

Development 

NTSB has recently taken several actions that, along with potentially better

practices in one modal office, may help shorten report development time. 

First, in response to a recommendation by Booz Allen Hamilton to gain 

management’s buy-in to the report message before writing the report and 

thereby reduce the number of review iterations, NTSB management has 

reemphasized its policy for report development meetings. NTSB has a 

long-standing order that calls for holding message development meetings 

with internal stakeholders who will be reviewing the report prior to report 

writing. According to a senior NTSB official, however, the agency had

stopped following that policy before Booz Allen Hamilton conducted its 

study in 2004. The official further stated that subsequent to that 

recommendation, NTSB’s managing director sent a memorandum 

reminding staff to follow the policy. While NTSB has no data on whether 

the message development meetings are actually taking place, officials told

us that the managing director’s recent emphasis on these meetings was 

resulting in more of them occurring than in previous years. 

Second, since the spring of 2005, NTSB has initiated production meetings 

with senior management with the goal of reducing the duration of 

investigations. These meetings occur every 2 weeks and focus on report 

development and production. NTSB modal directors are held accountable 

for a specific issuance date within a six month planning window prior to 

issuing a report. During the biweekly meetings, the directors discuss with 

NTSB’s Managing Director and senior executives their progress and 

commitments to complete the investigations. The meetings result in a 

production schedule that is available for subsequent review. The modal 

directors stated that they believe the new system is effective in reducing 

the duration of investigations; however because these meetings began so 

recently, it is too early to evaluate their effectiveness. 

Third, the highway office—which has the swiftest rate of accident 

investigation completion—uses a concept called a “project manager,” who 

serves as a supervisory writer editor and interface between the 

Page 25 GAO-06-801T 
investigative staff and the writer editor staff. As a result, the project 

manager assumes some of the report development roles typically 

supported by the investigators-in-charge. In comparison, investigators-incharge in the marine and rail, pipeline, and hazardous materials offices 

submit a draft report to the writer editor, who then edits and sometimes 

substantially rewrites the report. In aviation, investigators-in-charge do not 

write reports, but rather writer editors develop the final report from 

interim technical reports drafted by specialists on the team. Booz Allen 

Hamilton recommended that all modes use a project manager or deputy 

investigator-in-charge so that the expertise of staff can be used more fully. 

In addition, such a practice might alleviate some of the workload issues 

that writer editors face as they complete multiple reports. NTSB managers 

told us that they agree with this recommendation, but they have not 

implemented it or developed any milestones for implementation. 

Fourth, the highway safety office uses an incentive system for 

performance on developing reports. Booz Allen Hamilton reported the 

highway safety office rewards staff with a cash bonus for meeting key 

deadlines for producing accident reports. Again, the study recommended 

that the highway program be used as a model for the other modal offices. 

The study further recommended that the incentive program be slightly 

modified so that the incentives are based on delivering reports before 

deadlines, rather than meeting deadlines. In that way, the average time 

standard would be tightened and the overall report development time 

would be shortened. According to NTSB officials, they are currently 

examining how to implement improved awards and incentive programs 

that will result in improved quality and timeliness of report products. 

Safety Recommendations 

Close-out Process Is Time 

Consuming for Several 

Reasons 

The processes for federal transportation agencies to implement NTSB’s 

safety recommendations, and for NTSB to change the status of 

recommendations it has made, are also lengthy because of complex 

processes involving many players. As of May 2006, 305 of NTSB’s 852 open

recommendations had been open for 5 years or more. Lengthy processes 

for federal agencies to develop regulations to implement NTSB’s safety 

recommendations and industries to comply can work against the goal of 

quickly improving transportation safety. In addition, the lengthy, paperbased process for changing the status of recommendations ties up NTSB’s 

scarce resources. 

The length of time that NTSB recommendations remain open is due, in 

part, to challenges faced by federal transportation agencies in 

implementing those recommendations, particularly those that require 

Page 26 GAO-06-801T 
changes to federal regulations, which take many years to complete. DOT 

modal officials with whom we spoke cited a lengthy rule-making process, 

which includes budgeting and allocating resources to develop the 

proposed regulation, drafting and receiving comments on proposed rules, 

and waiting for the industry’s subsequent response to implement the final 

rule. For example, TWA flight 800 crashed off Long Island in July 1996; 

NTSB issued safety recommendations pertaining to explosive fuel tanks in 

December 1996. NTSB adopted the accident report with further 

recommendations to FAA to reduce flammable vapors in aircraft fuel 

tanks in 2000; FAA issued a notice of proposed rule to address this 

recommendation in November 2005; the comment period for the notice

ended on March 23, 2006. Thus, 10 years after the crash, the final rule has 

not been issued. Federal transportation officials also said the failure to 

satisfy a cost-benefit analysis might impede the implementation of NTSB 

recommendations. Although NTSB is required to only consider the safety 

implications of its recommendations and not consider the cost factors, if a 

proposed regulation is not cost beneficial, it cannot be approved by OMB. 

Federal officials with whom we spoke at DOT, which receives the bulk of 

NTSB recommendations, indicated that they have been working with 

NTSB to find acceptable means of implementing recommendations. The 

process—recently called Safety With a Team—is designed for NTSB and 

federal agencies to work in cooperation to address open recommendations 

and implement needed safety improvements. NTSB and DOT officials told

us that this process contributed to the closing of many recommendations. 

However, the process is not used with the Coast Guard, which has the 

lowest rate—74 percent—for accepting NTSB recommendations among 

the modes, as mentioned previously. According to a Coast Guard official 

we spoke with, the Coast Guard believes that it has an acceptable rate for 

closing NTSB recommendations and that it does not intend to act on 

recommendations that it deemed unnecessary. 

NTSB recognizes that open recommendations can have serious safety 

implications for the transportation industry. To spur implementation, the 

agency also publishes a “most wanted” list of what it considers the most 

serious safety concerns. For example, in 2000 NTSB added to its most 

wanted list the need to improve the safety of motor carrier operations. 

NTSB recommended that FMCSA prevent motor carriers from operating if 

they put vehicles with mechanical problems on the road or unqualified 

drivers behind the wheel. As recently as May 2006, NTSB issued an 

additional recommendation that FMCSA “establish a program to verify 

that motor carriers have ceased operations after the effective date of 

revocation of operating authority.” 

Page 27 GAO-06-801T 
The process that NTSB uses to change the status of or close out safety 

recommendations is paper-based, labor intensive, and relies on a series of 

sequential reviews; this process can take between 6 and 12 weeks. As a 

result, NTSB is delayed in communicating with agencies on whether NTSB 

considers the actions that have been taken to address the recommendation 

are sufficient to accept the recommendation. Consequently, agencies 

remain unaware that their response has been accepted or not accepted. 

And in the case of DOT, this lack of information affects its ability to 

accurately report annually to Congress on the status of implementing 

NTSB’s recommendations in all its modal administrations.23

The process of closing recommendations is managed by NTSB’s Safety 

Recommendation Office, which has responsibility for maintaining a 

recommendations database and administering the paper flow to change 

the status of recommendations. Adding complexity to the process—which

NTSB calls the “mail control process”—is the fact that there are 12 

separate categories of recommendations status. The 12 categories are 

listed in figure 10, which also shows the percentage of recommendations 

in each category as of May 1, 2006. 

 2349 USC Sec. 1135(d). NTSB pointed out that for those recommendations on the Most

Wanted List, it specifically updates the list each November to ensure sufficient time for 

DOT to file its annual report to Congress.

Page 28 GAO-06-801T 
Figure 10: Status Categories for Recommendations Issued From 1967 to 

May 1, 2006 

Note: NTSB issued 12,471 recommendations from 1967 to May 1, 2006. 

The process begins when NTSB receives documentation from the 

recommendation recipient that would change the recommendation’s 

status. The Safety Recommendation Office generates paper folders and 

supervises a process that is summarized in figure 11. This process involves

multiple, sequential approvals starting from the Safety Recommendation 

Office, to the modal offices and Research and Engineering Office, to the 

Managing Director’s office, to the board members for final approval. Since 

none of these reviews happen concurrently, some 150 folders are in 

process at any given time, according to the director of the Safety 

Recommendations Office. There are no electronic communications or 

Page 29 GAO-06-801T 
approvals throughout the process. In its study of NTSB, Booz Allen 

Hamilton identified this as an inefficient process. Officials at NTSB agree 

that efficiencies could be gained in this process and are considering 

eventually computerizing a number of processes such as this one. The

agency expects to develop such plans after hiring a chief information 

officer later this year. 

Figure 11: NTSB’s Recommendation Close-Out Process

Although there is no statutory requirement that revenues from NTSB’s 

academy would generate sufficient revenues to cover the costs, in July 

2005, NTSB was encouraged in the Senate report accompanying the Fiscal

Year 2006 DOT Appropriations Act to be more aggressive in imposing and 

collecting fees to cover the costs.24 The academy generates revenues 

through tuition fees, space rental to other agencies for events such as 

conferences, and contracts with federal agencies that would allow them to 

use academy space for “continuity of operations” in emergency situations. 

To the extent that NTSB maximizes the use of the academy, it can produce 

additional revenues that may help cover costs. 

NTSB’s Academy 

Does Not Generate 

Sufficient Revenues 

to Cover Costs and Is 

Not Fully Utilized 

 24Senate Report 109-109 accompanying P.L. 109-115, the Transportation, Treasury, the 

Judiciary, Housing and Urban Development, and Related Agencies Appropriations Act of

2006. 

Page 30 GAO-06-801T 
Academy Costs Have 

Exceeded Revenues 

For the first 2 full years of operation, fiscal years 2004 and 2005, NTSB’s 

academy did not generate sufficient revenues to cover the costs of 

providing training, as shown in table 1. As a result, those portions of the 

academy’s costs that were not covered by the revenues from tuition and 

other sources—approximately $6.3 million in fiscal year 2004 and $3.9 

million in fiscal year 2005—were offset by general appropriations to the 

agency. The salaries and other personnel related expenses associated with 

NTSB investigators and managers teaching at the academy, which would 

be appropriate to include in academy costs, are not included in table 1 

because NTSB told us that it does not choose to account for expenses in 

that manner. In addition, NTSB lacks a full cost-accounting system that 

would facilitate doing so. The table shows expenses directly associated 

with the academy and does not include an allocation of agency wide 

supporting services, such as the Managing Director’s office, information 

technology, human resources, and legal support. Some of the expenses 

during these 2 years were one-time expenses—such as over $125,000 for 

furniture and equipment (included in table 1 as office supplies for fiscal 

year 2005) and $499,000 to move the wreckage of the TWA flight 800 

airplane from storage near the crash site in New York to the academy 

(included in the table as miscellaneous government contract services in 

fiscal year 2004). Space rental is a fixed annual expense of about $2.5

million. When that fixed expense is excluded from academy expenses, the 

remaining operating expenses exceeded revenues by about $3.7 million in

fiscal year 2004 and about $1.4 million the subsequent year. 

Page 31 GAO-06-801T 
Table 1: Direct Expenses and Revenues for the NTSB Academy, Fiscal Years 2004

and 2005 (unaudited)

FY 2004 FY 2005 

Percentage

difference

Personnel related $1,011,716 $978,591 -3%

Travel $24,428 $56,912 133%

Space rentala$2,521,440 $2,500,896 -1%

Maintenance/repair of buildings $706,279 $238,203 -66%

Miscellaneous government contract 

services 

$2,204,880 $558,540 -75%

Office supplies $12,939 $153,249 1084%

Miscellaneous expensesb$29,320 $28,887 -1%

 Total expenses $6,511,002 $4,515,278 -31%

Earned revenue $258,760 $634,800 145%

Overall deficit -$6,252,242 -$3,880,478 -38%

Deficit when space rental expense is 

excluded -$3,730,802 -$1,379,582 -63%

Source: NTSB. 

a

NTSB leases the academy facility from George Washington University under a 20-year lease that will 

expire in 2021. 

b

Miscellaneous expenses such as telephone, mail, and photography services and printing. 

In addition, while some courses presented during the first 2 years of 

academy operation did not recover the costs that NTSB attributes to them, 

revenues from other courses exceeded the cost. Of the 49 class sessions 

provided at the academy in fiscal years 2004 and 2005, revenues from 14 

sessions, all of which occurred in fiscal year 2005, did not recover their 

cost, while revenues from the remaining sessions exceeded the cost.25

According to the academy’s deputy manager, courses are only expected to 

generate enough revenues to offset the costs specifically attributed to the 

course, with some additional allocation for research and development of 

other programs and, if possible, other academy costs. Accordingly, tuition

prices are determined by estimating those costs (such as course material, 

contracted instructors and their travel expenses) and dividing that cost by

the projected class size. Costs such as the building lease, maintenance, 

building security, and academy personnel are not allocated to the costs of

 25The revenue deficient for the 14 sessions totaled $54,279, and the revenue surplus for the

two years totaled $307,203.

Page 32 GAO-06-801T 
individual courses.26 In addition, consideration is given to setting tuition at

a level that is competitive with similar courses by other institutions and 

that is not prohibitively high for prospective students from government 

agencies, according to the academy official. 

Other sources of revenue are needed for NTSB to be able to recover the 

full costs of the academy. For fiscal year 2004, over $12,000 in revenue

(about 5 percent of total revenues) was collected from sources other than 

course fees to cover some of those costs. For fiscal year 2005, the revenue 

from other sources increased to over $91,000 (about 14 percent of total 

revenues). Other sources of income during these 2 years included renting 

space to other organizations, such as the Society of Automotive Engineers, 

George Washington University, and the National Association of State 

Boating Law Administrators for meetings, conferences, and boat storage. 

In addition, NTSB has contracted with two agencies—the Federal Energy

Regulatory Commission and the Virginia Circuit Courts—for continuity of

operations. According to NTSB officials, it has explored this option with 

other organizations, but has not found others who will pay a yearly 

retainer for the service.27 While NTSB has taken action to generate revenue 

from other sources, it does not have a business plan or marketing strategy

that seeks to optimize opportunities for additional revenues. According to

the academy’s deputy manager, NTSB plans to develop a business plan. 

The agency, however, has no timeframes for doing so. 

Our analysis of the academy lease indicates that NTSB has the flexibility to

use the facility in other ways to generate revenues or potentially reduce

costs. For example, the lease does not preclude NTSB from subletting 

unused space to other users. Since certain space is already configured as 

classrooms and the academy is located in an academic setting on George 

Washington University’s suburban Virginia campus, it may be possible to 

market space to academic users. Furthermore, NTSB is not precluded by 

its academy lease or its lease for headquarters space in Washington, D.C., 

from relocating some headquarters staff to the Virginia facility. The lease 

 26If the tuition fee is set by dividing the costs attributable to a course by the projected class 

size, the fee may not be competitive with fees charged by other institutions offering similar 

courses. In that case, the projected class size might not be attainable without lowering the 

tuition to a competitive level, with the result that fee revenues collected might not cover 

the attributable costs. 

27NTSB has a memorandum of understanding with GAO for the two agencies to reciprocate

in providing continuity of operations. There is no annual fee associated with this 

agreement, only cost reimbursement after the first 14 days of providing space. 

Page 33 GAO-06-801T 
for the office space in Washington, D.C., expires in 2011. Such a move, 

however, would incur one-time costs that include relocating staff, moving 

furniture and equipment, reconfiguring space and utilities as well as 

recurring travel costs for staff who must travel between the two locations. 

Such costs would have to be weighed against the reduced cost of leasing 

less space in Washington, D.C. 

Academy Classrooms Are 

Significantly Underutilized 

NTSB has not maximized the use of the facility, which could generate 

additional revenues that may help cover costs.28 We estimate that, overall, 

less than 10 percent of the total classroom space was used during fiscal 

year 2005.29 As shown in figure 12, none of the five classrooms were used 

for 21 weeks in fiscal year 2005. In addition, at any given time, no more 

than three classrooms were in use. Figure 12 shows the days in which 

classroom space was used for 31 class sessions and 12 other events, such

as workshops and seminars by organizations that rented the space during 

fiscal year 2005. 

 28The academy facility contains five classrooms, a large warehouse that houses aircraft and 

other wreckage, eating and lounge areas, and office space for five employees who 

constitute NTSB’s Washington field office. 

29We excluded federal holidays and the last week in December from our analysis. In some 

cases, courses used multiple classrooms. We lacked specific information on which courses

used multiple classrooms. To account for that situation, we rounded up the percentage of

space utilized. The use of multiple classrooms does not affect the information on the lack 

of using any classrooms for 21 weeks. 

Page 34 GAO-06-801T 
Figure 12: Utilization of Classrooms by Academy Classes and Other Events, Fiscal Year 2005 

Note: Bars indicate classroom use. For example, two stacked bars indicate that two classrooms were 

in use on a particular day. 

Page 35 GAO-06-801T 
While a relatively small percentage of the academy’s students have been 

NTSB staff, the agency is taking efforts to increase their enrollment at the 

academy. About 20 percent of the academy’s approximately 1,000 

students30 in fiscal year 2004 were NTSB staff, and about 14 percent of the 

1,400 students in fiscal year 2005 were NTSB staff. Over the 2 years, about

400 NTSB students31 attended 38 of the 49 class sessions conducted at the 

academy during fiscal years 2004 and 2005. (See fig. 13) NTSB is making 

efforts to have staff more fully utilize the facility. In fiscal year 2004, 1 of

18 sessions was only for NTSB investigators; in fiscal year 2005, 5 of 31

sessions were only for NTSB investigators.32 While increasing the use of 

the academy by NTSB staff would reduce the costs of sending them to 

external training, it is important that NTSB not reduce the number of 

external, paying students in the process. 

 30The total number of students is the sum of the participants in all classes. Individuals who 

attended more than one class at the academy were, therefore, counted multiple times. 

31Individuals that attend more than one class are counted multiple times. 

32These course sessions were Conducting Effective Technical Presentations; two sessions 

each of Media Training and Major Investigation Protocol and Processes; and a joint training 

class with the Federal Bureau of Investigation. 

Page 36 GAO-06-801T 
Figure 13: Number of NTSB and Non-NTSB Students, Fiscal Years 2004 and 2005 

NTSB staff receive most of their training from outside the academy, which 

may be due to the courses lacking the subject matter that they require. Our 

analysis of staff training requests for fiscal year 2006 showed that 97 

percent of all training is expected to be from external sources and the 

remaining training from NTSB’s academy. NTSB staff have requested 

external training being provided by organizations that include FAA’s 

Transportation Safety Institute, the University of Southern California, the 

U.S. Department of Agriculture, and Kettering University for training in 

subjects such as human factors in aviation safety, turbine engine 

investigation, or automotive design and safety. Training requests cover 

other specialties such as helicopter training, flight training currency for 

pilots, technical writing, supervisory and management skills, and industry 

conferences. Investigators and writer editors with whom we spoke had 

positive views on the quality of academy training courses but provided 

several reasons for not taking further courses there. Ten of the 23 

investigators and writer editors we interviewed told us that they had taken 

Page 37 GAO-06-801T 
(or taught) courses at the academy and thought the courses were 

excellent;33 none of the investigators and writer editors had anything 

negative to say about the quality of any academy course. However, none of

the staff we talked with had plans to attend academy training in fiscal year

2007. One reason noted for this situation was the remoteness of Ashburn, 

Virginia, from their residences. Another reason was the lack of courses on 

new transportation technologies and the skills and competencies needed 

by an investigator-in-charge. Eight investigators told us that they find 

workshops by manufacturers, such as aircraft and automobile 

manufacturers, more valuable to their work than academy training. 

The academy is not utilized more by NTSB staff, in part, because the 

agency has not developed a core curriculum for its staff that could then be

offered at the academy, as mentioned previously in this testimony. The 

academy only offers one course that is required for NTSB staff—-a 2-week 

course on aviation accident investigation that is required for new NTSB 

investigator staff. The deputy manager of the academy told us that the 

academy plans to eventually offer more internal training covering subjects 

such as management skills, retirement, and computers.34 However, no 

milestones or specific plans have been established for that effort. 

Although most students at the academy are from outside NTSB, several 

factors can affect the agency’s ability to attract additional outside 

students. First, the lack of a business or marketing plan may be affecting 

NTSB’s ability to fully utilize the academy. Second, academy training is 

similar to training provided by other institutions. FRA, FAA, and PHMSA 

officials told us that their investigators do not attend NTSB training 

because similar training is provided in-house by DOT’s Transportation 

Safety Institute. For example, an FAA investigator told us that new 

investigators take a basic accident investigation course at the 

Transportation Safety Institute and subsequently take mid-career followup courses there. Furthermore, our comparison of NTSB’s fiscal year 2006

curriculum with that of several other institutions that teach courses on 

accident investigations showed that other institutions offered courses 

similar to 12 of NTSB’s 19 courses. For example, DOT’s Transportation 

Safety Institute offers basic courses on aviation and bus accident 

 33Our review of course evaluations for fiscal years 2004 and 2005 indicated high positive 

responses by students to the academy courses. The data lacked information for us to 

compare evaluations by NTSB students and non-NTSB students. 

34NTSB is considering contracting out more courses such as these. 

Page 38 GAO-06-801T 
investigations, and the University of Southern California offers a course on 

human factors related to accident investigations. 

Additional Issues 

Concerning the Academy 

You asked that we provide information concerning the academy’s use of 

NTSB investigators as instructors and NTSB’s compliance with the AntiDeficiency Act, with regard to its accounting for its academy lease. 

Concerning the first issue, academy courses are taught by a combination 

of academy staff, NTSB investigators and managers, and contractors. Use 

of investigators as instructors is limited and is likely to have little impact 

on investigators’ overall workload. During fiscal year 2005, 51 NTSB 

investigators or managers taught at the academy. On average they spent an

estimated 22 hours to prepare for and teach courses. (See fig. 14.) 

Page 39 GAO-06-801T 
Figure 14: Length of Time NTSB Investigators Spent Teaching and Preparing to

Teach Academy Courses and the Length of Time All Other Instructors Spent 

Teaching, Fiscal Year 2005

Note: Other instructors include NTSB academy staff, volunteers, and contract instructors from outside

NTSB. Data on the number of hours “other” instructors spent preparing to teach is not collected by 

NTSB. 

Finally, NTSB classified its lease for the academy as an operating lease 

rather than a capital lease. As a result, NTSB has been noncompliant with 

the Anti-Deficiency Act because it did not obtain budget authority for the 

net present value of the entire 20-year lease obligation at the time the lease 

agreement was signed in 2001. NTSB realized the error in 2003 and 

reported its noncompliance to Congress and the President. NTSB has 

proposed in the President’s fiscal year 2007 budget to remedy this 

antideficiency act violation by inserting an amendment in their fiscal year 

2007 appropriation that would allow NTSB to fund this obligation from 

their salaries and expense account through fiscal year 2020. 

Page 40 GAO-06-801T 
Mr. Chairman, we have developed several conclusions from our analysis of

NTSB to date. To the credit of the current leadership at NTSB, much of the 

agency’s progress toward following leading practices is due to recent 

management initiatives. The performance management plan, draft staffing 

plan, and implementation of controls over financial transactions are all 

positive steps. NTSB’s progress in these areas will likely remain

incomplete without additional actions, however. For example, without a 

more comprehensive strategic plan than it currently has, NTSB cannot 

align staffing, training, or other human resource management to its 

strategic goals or align its organizational structure and layers of 

management with the plan. NTSB will also likely miss opportunities to 

strengthen the management of the agency until it develops a strategic 

training plan for its employees, implements a full cost-accounting system, 

and improves communications within the agency. 

We have also concluded that, despite the many safety recommendations 

NTSB has made and seen implemented over the years of its existence, 

inefficiencies have resulted from the process that the agency uses to close 

out safety recommendations. In particular, the absence of a computerized 

documentation system and the sequential reviews that NTSB currently 

requires slow the process and prevent expedient delivery of information 

about recommendation status to affected agencies. Finally, in terms of its 

academy, NTSB is missing opportunities to increase the value of this asset. 

Without a comprehensive marketing plan, NTSB will likely be unable to 

efficiently attract users who would help pay the ongoing costs of the 

facility. 

To improve the efficiency of agency operations, we are making eight 

recommendations to the Chairman of the National Transportation Safety

Board based on our completed work to date. To improve agency 

performance in the key functional management areas of strategic planning, 

human capital planning, financial management, and communications, we 

recommend that the Chairman implement the following three 

recommendations: 

Conclusions 

Recommendations for 

Executive Action 

• Improve strategic planning by developing a revised strategic plan that 

follows performance-based practices; developing a strategic training plan

that is aligned with the revised strategic plan and identifies skill gaps that 

pose obstacles to meeting the agency’s strategic goals and curriculum that 

would eliminate these gaps; and aligning their organizational structure to 

Page 41 GAO-06-801T 
implement the strategic plan and eliminate unnecessary management 

layers. 

• Develop a full cost-accounting system that would track the amount of time 

employees spend on each investigation and in training. 

• Develop mechanisms that will facilitate communications from staff-level 

employees to senior management, including consideration of contracting 

out a confidential employee survey to obtain employee feedback on 

management initiatives.

To enhance the efficiency of the report development and recommendation 

close-out processes, we recommend that the Chairman take the following

two actions: 

• Identify better practices in the agency and apply them to all modes. 

Consider such things as using project managers or deputy investigators-incharge in all modes, using incentives to encourage performance in report 

development, and examining the layers of review to find ways to 

streamline the process, such as eliminating some levels of review and 

using concurrent reviews as appropriate. 

• Improve the efficiency of the review process for changing the status of 

recommendations by computerizing the documentation and implementing 

concurrent reviews. 

To enhance the utilization of the academy and improve the ability to 

generate revenues that will cover academy costs, we recommend that the 

Chairman take the following three actions: 

• Develop a comprehensive marketing plan for the academy. The plan 

should consider such things as outreach to potential users, working with 

USDA and GSA to market it as classroom and conference space, and 

conducting market research for additional curriculum development. If 

ethical and conflict-of-interest issues can be addressed, the plan should 

also consider options for allowing transportation manufacturers to 

conduct company-sponsored symposia and technical training at the 

academy facility, which would benefit NTSB investigators in keeping up 

with new technologies. In addition the plan should consider the feasibility 

of subleasing a portion of the academy space. 

• Develop core investigator curriculum for each mode and maximize the 

delivery of that training at the academy. 

Page 42 GAO-06-801T 
• Conduct a study to determine the costs and feasibility of moving certain 

functions from headquarters to the academy facility in preparation for the

renegotiation of the headquarters lease, which expires in 2011. 

We obtained comments on a draft of this testimony from NTSB. NTSB’s 

Managing Director concurred with our recommendations and provided 

clarifying comments and technical corrections, which we incorporated as 

appropriate. In addition, NTSB commented that the draft did not 

sufficiently distinguish improvements that have been made over the past 

year. We revised the testimony to more clearly distinguish those actions.

To determine the extent to which NTSB is following leading practices in 

selected management areas, we reviewed past GAO work on leading 

management practices in the areas of strategic planning, performance 

management, human capital management, financial management, and 

communications. We interviewed NSTB board members, senior officials, 

managers, investigators, and writer editors regarding their experience with

those practices at NTSB, and their perceptions of the effectiveness of 

those practices. We also determined NTSB’s response to 

recommendations made by the DOTIG. We reviewed NTSB documents, 

including its strategic, staffing, and performance management plans; 

management advisory e-mail; and information regarding the current 

staffing levels; and employees’ training plans for 2006. 

To determine the extent to which NTSB is developing accident

investigation reports and closing safety recommendations in an efficient 

manner, we interviewed NTSB investigators, writer editors, managers, and

senior officials regarding the investigative process and their role in it. We

randomly selected 15 of the 210 investigators and 8 writer editors evenly 

across the 4 modal offices. The views represent the particular individuals 

and are not representative of all NTSB investigators and writer editors. We 

reviewed policy guidance on the investigative process and the level of 

current and past investigation activity. We examined data on 

recommendations acceptance rates and close-out status from NTSB’s 

recommendation database, and we determined that the data were 

sufficiently reliable for the objectives of this review. Additionally, we 

reviewed studies done by the Rand Corporation and Booz Allen Hamilton 

that examined NTSB’s investigation process and determined the extent to

Agency Comments 

Scope and 

Methodology 

Page 43 GAO-06-801T 
which the agency had implemented their recommendations. 

To determine the extent to which NTSB is generating sufficient revenues 

to cover costs at its academy, we reviewed financial data on NTSB’s 

academy, including the revenues and expenses for fiscal years 2004 and 

2005. We reviewed the course curriculum of the academy, and compared it

with classes offered by DOT’s Transportation Safety Institute, Embry 

Riddle, the University of Southern California, and the Southern California 

Safety Institute. We examined data on the student makeup of academy 

classes and analyzed data on the preparatory and teaching time used by 

NTSB investigators who taught at the academy. We interviewed NTSB 

investigators, writer editors, and managers and senior officials at DOT’s 

modal administrations regarding their current and planned use of the 

academy. Finally, we examined the lease for the academy to determine 

how NTSB may utilize the space. 

We conducted our review from December 2005 to May 2006 in accordance 

with generally accepted government auditing standards. 

For further information on this testimony, please contact Dr. Gerald 

Dillingham at (202) 512-2834 or by e-mail at dillinghamg@gao.gov. 

Individuals making key contributions to this testimony include Teresa 

Spisak, Colin Fallon, Eric Fielding, Tom Keightley, Maren McAvoy, Josh 

Ormond, and Jena Whitley. 

Page 44 GAO-06-801T 

Contacts and 

Acknowledgments 

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