United States Government Accountability Office

GAO Report to Congressional Requesters

NATIONAL 

TRANSPORTATION 

SAFETY BOARD 

Progress Made, Yet 

Management 

Practices, 

Investigation 

Priorities, and 

Training Center Use 

Should Be Improved 

November 2006 

 

GAO-07-118 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

November 2006

NATIONAL TRANSPORTATION SAFETY 

BOARD 

Progress Made, Yet Management 

Practices, Investigation Priorities, and 

Training Center Use Should Be Improved 

Highlights of GAO-07-118, a report to 

congressional requesters 

The National Transportation Safety

Board (NTSB) plays a vital role in

advancing transportation safety by 

investigating accidents, 

determining their causes, and 

issuing safety recommendations. 

To support its mission, NTSB’s 

training center, which opened in 

2003, provides training to NTSB 

investigators and others. It is 

important that NTSB use its 

resources efficiently to carry out its 

mission. GAO was asked to

examine the extent to which NTSB 

follows leading management 

practices, how NTSB carries out its 

transportation safety function, and 

the extent to which NTSB’s training 

center is cost-effective, including

potential options for improving the 

center’s cost-effectiveness. GAO 

reviewed NTSB documents and

data concerning management 

practices and accident

investigations, interviewed relevant 

NTSB and other federal officials, 

and evaluated NTSB’s management 

practices based on leading 

practices identified in prior work.

While NTSB has recently made progress in following leading management 

practices, its overall use of leading management practices in the seven areas 

GAO examined was either minimal or partial. NTSB minimally follows 

leading practices in strategic planning, information technology, and 

knowledge management. NTSB partially follows leading practices in human

capital management, communications, acquisition management, and 

financial accountability and control. For example, regarding human capital 

management, NTSB developed a detailed staffing plan. However, the agency

lacks a strategic training plan and a diversity management strategy, which 

are important for ensuring that an organization has strategies for achieving

the appropriate mix of skills to achieve its mission. In addition, while NTSB 

follows some leading practices for financial management, it is noncompliant 

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

the net present value of the entire 20-year lease for its training center lease

obligation at the time the lease agreement was signed in 2001. 

NTSB carries out its transportation safety function by selecting which 

accidents to investigate, investigating accidents and issuing 

recommendations, and taking proactive steps outside of specific accidents. 

For some transportation modes, NTSB has risk-based criteria for selecting

which accidents to investigate, while for others it does not. Such criteria are 

important to ensure NTSB is using its resources to achieve a maximum 

safety benefit, particularly because, by statute, NTSB must allocate a large 

proportion of its resources to investigating aviation accidents, which may 

reduce the number of staff that NTSB can use to investigate accidents in 

other modes that may have critical safety implications. To its credit, 

although accident investigations are sometimes lengthy, NTSB issues urgent

recommendations during the course of an investigation. In addition, NTSB 

proactively carries out its mission by conducting safety studies to consider 

issues that may be relevant to more than one accident. Safety studies, which 

sometimes result in recommendations, may also reduce the likelihood of 

recurrence of transportation accidents. Over the last 6 years, NTSB has 

conducted four safety studies. Industry stakeholders stated they would like 

NTSB to conduct more safety studies. 

NTSB’s training center is not cost-effective, as the combination of the 

training center’s revenues and external training costs avoided by NTSB 

staff’s use of the facility do not cover the center’s costs. In fiscal year 2005, 

costs exceeded revenues by $3.9 million. Furthermore, the training center 

has had a limited impact on avoiding external training costs, as the majority 

of NTSB staff training occurs externally. Potential strategies to increase 

revenues or decrease costs could increase the cost-effectiveness of the 

training center; however, vacating the space may be the least-cost strategy. 

What GAO Recommends

GAO recommends that NTSB fully 

implement leading management 

practices, develop risk-based 

criteria for determining which

accidents to investigate, increase

its utilization of safety studies, 

determine whether to develop a 

business plan to increase the

utilization of its training center or 

vacate it, and take steps to rectify 

its violation of the Anti-Deficiency 

Act. NTSB agreed with the 

recommendations. 

www.gao.gov/cgi-bin/getrpt?GAO-07-118.

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. 
Contents 

Letter 1

Results in Brief 3

Background 6

NTSB Has Made Recent Progress in Following Leading 

Management Practices, but Overall Record Remains Mixed 15 

NTSB Carries Out Its Transportation Safety Function by 

Investigating Accidents, Issuing Recommendations, and Taking 

Proactive Steps Outside of Specific Accidents 32 

NTSB’s Training Center Is Not Cost-Effective; Options Could 

Increase Cost-Effectiveness, but Vacating Space May Be LeastCost Strategy 45 

Conclusions 57

Recommendations for Executive Action 58 

Agency Comments 59 

Appendix I Scope and Methodology 60 

Appendix II Prior GAO Recommendations to NTSB 64 

Appendix III Additional Analysis of NTSB Safety 

Recommendations Data 66 

Appendix IV Comments from the National Transportation 

Safety Board 74 

Appendix V GAO Contact and Staff Acknowledgments 76 

Related GAO Products 77 

Page i GAO-07-118 National Transportation Safety Board
Tables 

Table 1: Number of Accident Investigations Completed by NTSB by 

Mode, Fiscal Years 2002-2005 9 

Table 2: NTSB Training Center and Headquarters Capital Assets, as 

of September 2006 12 

Table 3: Number of Public Hearings by Mode, Calendar Years 1997-

2006 40 

Table 4: Number of Safety Studies by Mode, Calendar Years 2000–

2005 44 

Table 5: Direct Expenses and Revenues for the NTSB Training 

Center, Fiscal Years 2004 and 2005 (unaudited) 46 

Table 6: Entities Interviewed by GAO 61 

Table 7: Safety Recommendation Data Fields Analyzed 62 

Table 8: Number and Percentage of NTSB Safety

Recommendations with Closed Acceptable, Closed 

Unacceptable, and Open Status by Mode, for 

Recommendations Issued Calendar Years 1996-2005 72 

Figures 

Figure 1: Key Laws, Regulations, and NTSB Policies for 

Investigations by Mode 8 

Figure 2: NTSB’s Organization 10 

Figure 3: Number of NTSB Investigators and Technical Staff, Fiscal 

Years 2000-2007 11 

Figure 4: Components of an NTSB Investigation and 

Recommendation Closeout 13 

Figure 5: Extent to Which NTSB Follows Leading Practices in

Selected Management Areas 16 

Figure 6: Extent to Which NTSB’s Strategic Plan Follows GPRA 

Elements 17

Figure 7: Extent to Which NTSB Follows Leading Practices in

Selected Human Capital Management Areas 18 

Figure 8: Leading Practices in Diversity Management 23 

Figure 9: Legislative, Regulatory, and Other Criteria for Identifying 

Accidents to Investigate, by Mode 33 

Figure 10: Average Duration of Accident Investigations for Which 

Recommendations were Issued, Calendar Years 1996-2006 37 

Figure 11: Acceptance Rate by Mode, Calendar Years 1996-2006 41 

Page ii GAO-07-118 National Transportation Safety Board
Figure 12: Percentage and Number of Open Recommendations 

with Unacceptable Agency Action Issued During Calendar 

Years 1996-2006 42 

Figure 13: Number of NTSB and Non-NTSB Students, Fiscal Years 

2004-2006 48

Figure 14: Utilization of Training Center Classrooms by Classes and 

Other Events, Fiscal Year 2006 51 

Figure 15: Number of Recommendations by Mode of 

Transportation and by Year Issued, Calendar Years 1996-

2006 66

Figure 16: Number of Accident Investigations with Safety 

Recommendations, Calendar Years 1996-2006 67 

Figure 17: Number of Investigations Completed by Mode, Calendar 

Years 1996-2006 68 

Figure 18: Average Investigation Duration by Mode, Calendar Years 

1996-2006 70

Figure 19: Percentage of Safety Recommendations Open for at 

Least 5 Years, by Mode 73 

Page iii GAO-07-118 National Transportation Safety Board
Abbreviations 

CFO Chief Financial Officer

CIO Chief Information Officer 

CMMI Capability Maturity Model® Integration 

DOT Department of Transportation 

DOT IG Department of Transportation’s Inspector General

FAA Federal Aviation Administration 

FHWA Federal Highway Administration 

FMCSA Federal Motor Carrier Safety Administration 

FRA Federal Railroad Administration 

FTA Federal Transit Administration 

GSA General Services Administration 

GPRA Government Performance and Results Act of 1993

IDEAS Interior Department Electronic Acquisition System 

IT information technology 

NHTSA National Highway Traffic Safety Administration 

NTSB National Transportation Safety Board 

OPM Office of Personnel Management 

PHMSA Pipeline and Hazardous Materials Safety Administration 

TSI Transportation Safety Institute 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page iv GAO-07-118 National Transportation Safety Board
United States Government Accountability Office

Washington, DC 20548 

November 22, 2006 

The Honorable Ted Stevens 

Chairman 

Committee on Commerce, Science, and Transportation 

United States Senate 

The Honorable Ted Stevens 

Chairman 

Committee on Commerce, Science, and Transportation 

United States Senate 

The Honorable Daniel Inouye 

Co-Chairman 

Committee on Commerce, Science, and Transportation 

United States Senate 

The Honorable Daniel Inouye 

Co-Chairman 

Committee on Commerce, Science, and Transportation 

United States Senate 

The Honorable James L. Oberstar 

Ranking Democratic Member 

Committee on Transportation and Infrastructure 

House of Representatives 

The Honorable James L. Oberstar 

Ranking Democratic Member 

Committee on Transportation and Infrastructure 

House of Representatives 

With a staff of 386 and a budget of $76.7 million in fiscal year 2006, the 

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

that plays a vital role in advancing transportation safety by investigating

accidents, determining their causes, and issuing safety recommendations. 

From its creation in 1966 through 2006, NTSB has investigated more than 

134,000 accidents in aviation and other modes of transportation and has 

issued over 12,500 safety recommendations across all modes. To support 

its mission, NTSB leases a training center that opened in 2003 and 

provides training to NTSB investigators and other transportation safety 

professionals. While new transportation technologies and NTSB’s safety 

recommendations have made transportation safer than ever, the expected 

increase in the demand for all transportation modes will potentially place 

a strain on the ability of NTSB to continue playing its vital role in ensuring 

a safe transportation system in the United States. As the nation’s large and

growing long-term fiscal imbalance demands a growing share of federal 

resources, and a wide range of emerging needs and demands compete for 

a share of the budget, it is critical that NTSB use its resources in an 

efficient manner to carry out its safety mission and maintain its 

preeminent position. 

With a staff of 386 and a budget of $76.7 million in fiscal year 2006, the 

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

that plays a vital role in advancing transportation safety by investigating

accidents, determining their causes, and issuing safety recommendations. 

From its creation in 1966 through 2006, NTSB has investigated more than 

134,000 accidents in aviation and other modes of transportation and has 

issued over 12,500 safety recommendations across all modes. To support 

its mission, NTSB leases a training center that opened in 2003 and 

provides training to NTSB investigators and other transportation safety 

professionals. While new transportation technologies and NTSB’s safety 

recommendations have made transportation safer than ever, the expected 

increase in the demand for all transportation modes will potentially place 

a strain on the ability of NTSB to continue playing its vital role in ensuring 

a safe transportation system in the United States. As the nation’s large and

growing long-term fiscal imbalance demands a growing share of federal 

resources, and a wide range of emerging needs and demands compete for 

a share of the budget, it is critical that NTSB use its resources in an 

efficient manner to carry out its safety mission and maintain its 

preeminent position. 

In light of NTSB’s expansive mission to investigate transportation 

accidents across all modes and its relatively limited resources to 

accomplish this mission, you asked us to assess the agency’s management 

practices and accident investigation activities in order to provide 

In light of NTSB’s expansive mission to investigate transportation 

accidents across all modes and its relatively limited resources to 

accomplish this mission, you asked us to assess the agency’s management 

practices and accident investigation activities in order to provide 

Page 1 GAO-07-118 National Transportation Safety ortation Safety Board
information to be considered during the reauthorization of NTSB. In doing

so, we addressed the following questions: (1) To what extent does NTSB 

follow leading management practices? (2) How does NTSB carry out its 

accident investigation function? and (3) Is NTSB’s training center a costeffective investment, and how could it be more cost-effective? 

To determine the extent to which NTSB follows leading practices, we 

compared NTSB’s practices with criteria from our past work in functional 

areas that we consider important for an agency to perform well in—

strategic planning, human capital management, communications, 

acquisition management, financial accountability and control, information 

technology (IT), and knowledge management. We did not evaluate NTSB’s 

performance in the area of capital decision making because the agency

does not have a large amount of either capital assets or capital 

acquisitions. With assistance from GAO specialists in the functional areas, 

we assessed whether NTSB was mostly following the practices (plans or 

policies for all or nearly all practices have been developed and 

implemented properly), partially following them (plans or policies are in 

place and implemented properly for some practices), or minimally 

following them (plans or policies are lacking for all or nearly all practices).

We also reviewed NTSB’s responses to recommendations in some of these 

functional management areas made by us and the Department of 

Transportation’s Inspector General (DOT IG) in recent years. We 

interviewed current and former NTSB board members, senior officials, 

and division managers regarding their experience with those practices at 

NTSB and their perceptions of the effectiveness of those practices. We 

reviewed NTSB documents including orders, operations bulletins, 

investigative manuals, management plans, and applicable legislation. To 

determine how NTSB carries out its accident investigation function, we 

interviewed current and former board members, senior officials, division 

managers, and selected staff. We randomly selected 17 of the 203 

investigators and 8 writer-editors, who assist in writing accident 

investigation reports, roughly evenly across NTSB’s four modal offices.1

The views represent the particular individuals and are not representative

of all NTSB investigators and writer-editors. We also interviewed industry 

and government stakeholders, including federal agencies that receive

NTSB recommendations; aviation, rail, marine, and highway associations; 

and transportation safety advocacy groups. In addition, we examined data 

 1

The four offices are Aviation Safety; Highway Safety; Marine Safety; and Railroad, 

Pipeline, and Hazardous Materials Safety. 

Page 2 GAO-07-118 National Transportation Safety Board
on the number and implementation status of safety recommendations 

from NTSB’s recommendation database, and we determined the data were

sufficiently reliable for this review. We reviewed legislation, policy 

guidance, and NTSB data on the investigative process. Additionally, we 

reviewed studies by RAND Corporation and Booz Allen Hamilton that 

examined NTSB’s investigation process and determined the extent to 

which the agency had implemented their recommendations. To determine 

the extent to which NTSB’s training center is a cost-effective investment 

and how it could be more cost-effective, we reviewed financial data on

NTSB’s training center, including the revenues and expenses for fiscal 

years 2004 and 2005, and we examined NTSB’s lease to determine how 

NTSB may utilize the space. We conducted our review from December 

2005 to November 2006 in accordance with generally accepted government 

auditing standards. For more information on our scope and methodology, 

see appendix I. 

While NTSB has recently made progress in following leading management 

practices in the seven areas we examined, overall, it either minimally or 

partially has plans or policies in place to implement those practices. NTSB

minimally follows leading practices in strategic planning, IT, and 

knowledge management. NTSB partially follows leading practices in the 

areas of human capital management, communications, acquisition 

management, and financial accountability and control. For example, 

NTSB’s strategic plan lacks results-oriented objectives and specific 

strategies for achieving them, which are important practices in helping an

agency to define and support its mission, as well as a strategy for 

managing a diverse workforce as part of the strategic plan’s discussion of 

human capital. In May 2006, we recommended that NTSB improve its 

strategic plan, and it is taking steps to do so.2

 Regarding IT, in previous 

work we identified key elements of an IT program—an IT strategy,

enterprise architecture, IT investment management, and information 

security—that can help agencies maximize the value of their IT

investments and improve agency performance. While NTSB has made 

recent progress in correcting some information security vulnerabilities 

identified by the DOT IG, the agency has not completed its information 

security efforts, developed an IT strategic plan, established an enterprise 

Results in Brief 

 2

GAO, National Transportation Safety Board: Preliminary Observations on the Value of

Comprehensive Planning, and Greater Use of Leading Practices and the Training 

Academy, GAO-06-801T (Washington, D.C.: May 24, 2006). 

Page 3 GAO-07-118 National Transportation Safety Board
architecture, or initiated an IT investment management process. In 

addition, NTSB does not have a knowledge management initiative (i.e., a 

way for an organization to create, capture, and reuse knowledge to 

achieve its objectives) or a Chief Information Officer, which are essential 

to improving an organization’s ability to create and share knowledge, 

including data and information. NTSB is partially following leading 

practices in human capital management. For example, NTSB developed a 

staffing plan that addresses the agency’s skills, competency needs, and 

hiring strategies to strengthen the agency’s ability to carry out its 

transportation safety mission. However, the agency lacks a strategic 

training plan, which is important for ensuring that an organization has 

strategies for developing and training staff with the appropriate mix of 

skills and capabilities to achieve its mission. With regard to 

communication practices, NTSB has recently taken positive steps to 

improve communications from senior management to the staff—such as 

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

developments and policies. However, the agency lacks upward 

communications mechanisms, which are central to forming effective 

partnerships within the organization. In May 2006, we made 

recommendations in this area, and NTSB is taking steps to follow them.3

While NTSB is partially following leading acquisition practices, such as 

having a Chief Acquisition Officer and strategically assessing acquisition 

needs, the agency does not have an acquisition policy to guide IT 

activities, thereby increasing the risk that the agency will not be able to 

effectively manage new IT programs as they are acquired and come online. 

Finally, NTSB follows some leading practices for financial accountability 

and control and has received an unqualified or “clean” opinion from 

independent auditors on its financial statements in recent years. However, 

the agency 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. In addition, it has also 

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

for the net present value of the entire 20-year lease for its training center 

lease obligation at the time the lease agreement was signed in 2001. 

NTSB carries out its transportation safety function by selecting which 

accidents to investigate, sometimes using outside sources of expertise to 

help it determine the probable cause of those accidents, issuing 

suggestions and recommendations, and taking proactive steps outside of 

 3

GAO-06-801T. 

Page 4 GAO-07-118 National Transportation Safety Board
specific accidents. For some transportation modes, NTSB has detailed, 

risk-based criteria for selecting which accidents to investigate, while for 

others it does not. For example, in an effort to manage resources and 

ensure the maximum safety benefit, NTSB has a process to identify 

highway accidents for investigation based on the severity of the accident 

and amount of property damage. By comparison, NTSB lacks a 

documented policy with criteria for selecting rail, pipeline, and hazardous 

materials accidents to investigate. Instead, the decision to investigate an

accident is made by the office Director based on his judgment. As a result, 

for these modes, the agency lacks assurance and transparency that it is 

managing resources in a manner that ensures a maximum safety benefit. 

Such criteria are also important because NTSB does not have enough 

resources to investigate all accidents. Moreover, NTSB must allocate a 

large proportion of its resources to investigating aviation accidents due to

a statutory requirement that NTSB investigate all civil aviation accidents, 

including general aviation accidents. In fact, NTSB investigated nearly

2,000 aviation accidents in 2005 compared with 47 in all the other 

transportation modes combined. This requirement, therefore, reduces the 

number of staff that NTSB can use to investigate accidents in other modes 

that may have broader or more critical safety implications. To its credit, 

although accident investigations are sometimes lengthy, NTSB takes steps 

to ensure that recommendations for improving transportation safety are 

made available to the transportation industry before a report is issued by 

making “urgent” recommendations and suggestions for improvement 

during the course of an investigation. Since 2001, according to NTSB’s 

records, 256 NTSB suggestions have been implemented. Another strength 

of NTSB’s process is its use of external sources of technical expertise and 

occasionally public hearings. Finally, NTSB proactively accomplishes its 

transportation safety function by conducting public forums and safety 

studies to consider safety issues that may be relevant to more than one 

accident in order to provide improvements to transportation safety. Safety

studies, which sometimes result in recommendations, are intended to 

improve transportation safety by affecting changes to policies, programs, 

and activities of federal agencies that regulate transportation safety. Over

the last 6 years, NTSB has conducted four safety studies. Industry 

stakeholders stated they would like NTSB to conduct more safety studies

because the studies address NTSB’s mission in a proactive way, allowing 

for trend analysis and preventative actions. According to NTSB, the 

number of safety studies it conducts is resource driven. 

While NTSB staff and other students at NTSB’s training center have been 

positive about the quality of the courses, NTSB’s training center is not 

cost-effective, as the combination of the training center’s revenues and

Page 5 GAO-07-118 National Transportation Safety Board
external training costs avoided by NTSB staff’s use of the facility do not 

cover the training center’s costs. For the first 2 full years of operation, 

fiscal years 2004 and 2005, NTSB’s training center did not generate 

sufficient revenues to cover the costs of providing training there. As a 

result, those portions of the training center’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. Moreover, thus far the training 

center has had a limited impact in terms of avoiding external training 

costs, as the majority of NTSB staff training occurs externally. Revenues 

generated by the training center are affected by several factors, including 

low utilization of the facility and the availability of similar courses 

elsewhere that may reduce the number of students interested in NTSB 

classes. Potential strategies to increase revenues or decrease costs could 

increase the cost-effectiveness of the training center. For example, NTSB 

could attempt to increase training center revenues by attracting more 

external students, or decrease its external training costs by focusing on 

gearing more courses to NTSB staff, but it may be difficult to accomplish 

either of these strategies sufficiently to significantly affect the training 

center’s overall deficit, since NTSB lacks a market niche for its course 

offerings, and NTSB’s external training costs for its staff—approximately 

$1 million annually—are well below the $3.9 million deficit in fiscal year 

2005. NTSB could also sublet space to other users, such as academic 

users, but subleasing may not help NTSB to recover training center costs.

NTSB could also consider relocating some headquarters staff to the 

training center, although such a move would incur other costs. NTSB 

officials agreed with our analysis that vacating the space may be the leastcost strategy, even if NTSB had to buy out the remaining lease.

To improve overall agency operations, we recommend that NTSB fully 

implement leading management practices in several areas, develop riskbased criteria for determining which accidents to investigate in all modes, 

increase its utilization of safety studies, finalize a solution to its AntiDeficiency Act violation that has continued since the signing of the lease 

in 2001, and develop a business plan to either increase the utilization of its 

training center or vacate it. NTSB agreed with these recommendations. 

NTSB was established in 1966 as an independent government agency

located within the newly formed Department of Transportation (DOT).4

 In Background 

 4

Department of Transportation Act, Pub. L. No. 89-670, Oct. 15, 1966. 

Page 6 GAO-07-118 National Transportation Safety Board
1974, Congress made NTSB completely separate from DOT.5

 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. 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 in 

deciding whether to investigate highway accidents. 

 5

Independent Safety Board Act, Pub. L. No. 93-633, Title III, 1974. 

Page 7 GAO-07-118 National Transportation Safety Board
Figure 1: Key Laws, Regulations, and NTSB Policies for Investigations by Mode

49 U.S.C. 1131 (a)(1)(A)

49 C.F.R. part 800

International Civil Aviation Organization 

annex 13

Investigates or causes to be investigated all civil and certain public aircraft 

accidents in the United States and participates in the investigation of 

international accidents where the United States is the state of registry, 

operator, designer, or manufacturer.

49 U.S.C. 1131 (a)(1)(B)

49 U.S.C. 1131 (a)(1)(D)

Investigates selected accidents including railroad grade crossing accidents, 

which NTSB selects in cooperation with a state. 

49 U.S.C. 1131(a)(1)(C); 1116(b)(5)

49 C.F.R. part 840

Investigates railroad accidents involving a fatality, substantial property 

damage, or a passenger train. 

Investigates pipeline accidents in which there is a fatality, substantial 

property damage, or significant injury to the environment. 

49 U.S.C. 1116(b)(5) Investigates releases of hazardous materials in any mode that involves a

fatality, substantial property damage, or significant injury to the environment. 

For all modes, NTSB also evaluates the adequacy of safeguards and 

procedures for the transportation of hazardous materials and the 

performance of other departments, agencies, and instrumentalities of the 

government responsible for the safe transportation of that material.

Aviation 

Highway

Railroad

Pipeline 

Hazardous materials

All modes

49 U.S.C. 1131(a)(1)(E); 1131(b)

49 C.F.R. part 850

U.S. Coast Guard/NTSB 

memorandum of understanding from 

9/12/2002

Investigates selected major accidents and incidents, collisions involving 

public vessels with any nonpublic vessel, accidents involving significant 

safety issues related to Coast Guard safety functions, and international 

accidents within the territorial seas and where the United States is the state 

of registry. Major marine accidents are defined as a casualty that results in 

(1) the loss of six or more lives; (2) the loss of a mechanically propelled 

vessel of 100 or more gross tons; (3) property damage initially estimated as

$500,000 or more; or (4) serious threat, as determined by the Commandant 

of the Coast Guard and concurred with by the Chairman of NTSB, to life, 

property, or the environment by hazardous materials. 

Marine

Mode Key laws, regulations, and policies Investigation policy

Source: GAO summary of law, regulations, and policies.

Investigates selected accidents that are catastrophic or of a recurring nature.

Unlike regulatory transportation agencies, such as the Federal Aviation 

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

regulations to promote safety, but it makes recommendations in its 

accident investigation reports and safety studies to other agencies that 

have such regulatory authority. The federal agencies that receive NTSB 

Page 8 GAO-07-118 National Transportation Safety Board
recommendations6

 include 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 within the Department of Homeland Security. Some of these federal 

agencies—including FAA, FRA, and the Coast Guard—also conduct 

transportation accident investigations. Table 1 shows NTSB’s workload by 

transportation mode over 4 years. 

Table 1: Number of Accident Investigations Completed by NTSB by Mode, Fiscal 

Years 2002-2005 

Mode 2002 2003 2004 2005

Aviationa1,949 1,997 1,870 1,937

Highway 52 45 45 33

Rail 11 9 12 8

Pipeline 1 2 2 1

Hazardous materials 2 1 2 1

Marine 6 6 7 4

Source: GAO analysis of NTSB data. 

a

Aviation accidents include limited investigations in which NTSB delegates the gathering of on-scene 

information to FAA inspectors. 

NTSB’s Organization and 

Resources 

NTSB’s board is composed of five members nominated by the President 

and confirmed by the Senate.7

 The Chairman is NTSB’s Chief Executive 

and Administrative Officer. As of September 2006, the board was 

supported by a staff of 386, which includes 203 investigators and technical 

staff assigned to four modal offices—aviation; highway; marine; and rail, 

pipeline, and hazardous materials—and the Office of Research and 

Engineering. Figure 2 shows NTSB’s organization.

 6

NTSB also makes recommendations to others, such as state transportation authorities and

industries. 

7

The Chairman is nominated by the President with the advice and consent of the Senate. 

The Vice Chairman is appointed by the President. 

Page 9 GAO-07-118 National Transportation Safety Board
Figure 2: NTSB’s Organization 

Office of

General Counsel

Communications

Center

Executive

Secretariat

Training

Center

Office of

Management

Equal Employment

Opportunity

Director

Office of

Chief Financial

Officer

Member Vice-chairman Chairman Member Member

Office of

Administration

Office of Safety

Recommendations

and Communications

Office of

Aviation Safety

Office of

Marine Safety

Office of

Highway Safety

Office of Railroad,

Pipeline and

Hazardous Materials

Safety

Office of

Research and

Engineering

Office of

Administrative

Law Judges

Office of

Chief Information

Officer

Source: NTSB.

The agency is headquartered in Washington, D.C., and maintains 10 field 

offices nationwide and a training center in Ashburn, Virginia, in suburban 

Washington, D.C. In recent years, the agency has shrunk in size. In 2003,

NTSB had 438 full-time employees compared with 386 in September 2006. 

During the same period, the number of full-time investigators and 

technical staff decreased from 234 to 203. (See fig. 3.) NTSB’s modal 

offices vary in size in relation to the number of investigators; as of 

September 2006, the aviation office had 102 investigators and technical 

staff; the rail, pipeline, and hazardous materials office had 31; the highway 

office had 22; and the marine office had 12 employees. An additional 36

technical staff worked 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. 

Page 10 GAO-07-118 National Transportation Safety Board
Figure 3: Number of NTSB Investigators and Technical Staff, Fiscal Years 2000-2007

Source: GAO analysis of NTSB data.

Fiscal year

Number of staff

180

0

190

200

210

220

230

240

2000 2001 2002 2003 2004 2005 2006 2007

Note: Fiscal years 2000 and 2001 data are presented as of the second month of the fiscal year. 

Fiscal years 2002-2006 are presented as of the first pay period for each fiscal year. Fiscal year 2007

is presented as of the last pay period of fiscal year 2006. 

NTSB has approximately $28 million in capital assets. The vast majority of 

these assets—88 percent of the value—are made up of the capital lease on

the training center and equipment, furniture, and desktop computers to 

furnish the training center. (See table 2.) 

Page 11 GAO-07-118 National Transportation Safety Board
Table 2: NTSB Training Center and Headquarters Capital Assets, as of September 

2006 

Training center Acquisition value

Lease value $23,731,941

Equipment value 211,485

Furniture value 347,641

Desktop computers value 307,353

Training center total value $24,598,420

Headquarters

Materials lab $1,590,797

All other headquarters value 1,862,188

Headquarters total value $3,452,985

Training center and headquarters total value $28,051,405

Source: GAO analysis of NTSB data. 

Note: NTSB leases the training center under an operating lease. 

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 

requested $79.6 million for NTSB in fiscal year 2007.8

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

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

NTSB tracks the progress of implementing the recommendations during a 

fifth closeout phase. Figure 4 describes these phases. 

 8

As of November 3, 2006, the House had approved NTSB’s fiscal year 2007 budget at

$81,594,000, and the Senate Appropriations Committee approved a level of $79,594,000. 

Page 12 GAO-07-118 National Transportation Safety Board
Figure 4: Components of an NTSB Investigation and Recommendation Closeout 

 Launch

• Duty officer learns

about accident.

• Modal director 

recommends

launch.

• Chairman approves

launch.

• Communications

Center coordinates

logistics.

• IICa

 manages

accident 

investigation.

• Office of 

Transportation 

Disaster Assistance 

assists families and 

victims’ 

representatives at 

major accidents.

 Closeout

• Safety 

recommendations

office tracks

recommendations.

• Safety 

recommendations

office routes mail 

control sheets and 

obtains sign-offs.

• Board approves

recommendation 

status changes.

 Fact finding

• Team gathers onscene information.

• NTSB interviews

witnesses.

• Parties support 

gathering of 

information.

• NTSB may work 

with parties or 

contractors on 

testing and 

research.

• Public hearing may 

be held.

• Group chairmanb

prepares factual 

report. 

Source: GAO analysis of NTSB information.

 Analysis

• Parties submit 

technical analysis.

• Group chairman 

submits analysis.

• Management 

discusses and 

approves findings.

 Production

• IIC packages group 

chairman information 

and develops draft.

• Writer works with 

group chairman 

information to 

complete draft.

• Editors finalize 

product and 

management 

approves.

• Layout typesets

report.

• Board adopts

report.

a

IIC is the “investigator-in-charge.” 

b

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

for a particular area of an investigation. 

When a major accident9 occurs, a team of investigators is dispatched 

usually within hours of notification of the accident. All marine, rail, 

pipeline, hazardous material, and highway accidents10 that NTSB 

investigates are designated as major accidents. For aviation accidents, 

NTSB conducts on-scene investigations of major accidents and more 

limited investigations of accidents not designated as major. In some cases, 

 9

NTSB defines a major accident as one that involves an issue related to a current safety 

study or special investigation, impacts public confidence or transportation safety in a 

significant way, or is catastrophic. 

10NTSB investigates accidents involving all types of highway vehicles, including 

automobiles, buses, and trucks.

Page 13 GAO-07-118 National Transportation Safety Board
for on-scene investigations, the team members must set aside the 

investigations they have been working on to begin fact-finding on the new 

accident. The team begins the on-scene investigation as quickly as possible 

and assembles the technical expertise that is needed to solve sometimes 

complex transportation safety problems associated with the accident. The 

team’s leader is a senior investigator called the “investigator-in-charge;” 

other investigators contribute as specialists responsible for a clearly 

defined portion of the accident investigation.11 Under the direction of the 

investigator-in-charge, each NTSB investigator heads a working group in 

one area of expertise, which is staffed by representatives of the “parties” 

to the investigation. Parties are typically entities that can provide the 

necessary technical assistance to the investigation.12 For example, parties 

to an aviation accident may be the aircraft manufacturer and the pilots’ 

union; by statute, FAA is always a party to aviation investigations. At 

major accidents, NTSB’s Office of Transportation Disaster Assistance13

ensures that families and victims’ representatives have access to 

information concerning an accident throughout each phase of the 

investigation. This office coordinates briefings and provides support to 

families at the accident site by answering questions and guiding the 

families through the investigation process.14

Upon analyzing information obtained from parties and other sources, 

NTSB analysts prepare the accident investigation report, which is then 

reviewed throughout the agency. A report is typically reviewed by the 

 11For example, in aviation, these specialists and their responsibilities are operations,

structures, power plants, systems, air traffic control, weather, human performance, and 

survival factors. Locomotive engineers, signal system specialists, and track engineers head

working groups at railroad accidents. The specialists at a highway accident include a truck

or bus mechanical expert and a highway engineer. The agency’s weather, human 

performance and survival factors specialists respond to accidents of all kinds. 

12Only those persons who can provide NTSB with needed technical or specialized expertise 

are permitted to serve on the investigation; persons in legal or litigation positions are not

allowed to be assigned to the investigation. 

13The Office of Transportation Disaster Assistance is located in NTSB’s Office of Safety 

Recommendations and Communications. Family affairs specialists accompany the team to 

fulfill NTSB’s responsibilities under the Aviation Disaster Family Assistance Act of 1996, 

Pub. L. No. 104-264, Title VII–Family Assistance, October 9, 1996. 

14After the on-scene investigation has been concluded, the Office of Transportation 

Disaster Assistance continues its assistance through a dedicated telephone answer line that

families and victims’ representative can call and receive information with a guaranteed 

response time of 2 hours. Family members are also notified of other events relating to the 

accident such as public hearings and receive the final investigative report. 

Page 14 GAO-07-118 National Transportation Safety Board
modal office, the Office of Research and Engineering, the Executive

Secretariat, the Office of Safety Recommendations and Communications, 

the Office of General Counsel, and the Managing Director’s Office. A final 

report is then submitted to each board member and the Chairman perhaps 

12 to 18 months from the date of the accident. Final reports typically

include recommendations. 

Through our work governmentwide, we have identified a number of 

leading practices in areas that are important for managing an agency. 

Although NTSB is a relatively small agency, such practices are relevant for 

any agency. We evaluated NTSB’s practices based on leading practices 

identified in prior GAO work. (Related GAO products are listed at the end 

of this report.) In May 2006, we reported preliminary information 

concerning how NTSB’s practices compare with leading practices in the 

areas of strategic planning, human capital management, communications, 

and financial accountability and control.15 This report focuses on NTSB’s 

performance in those areas, as well as acquisition management, IT, and 

knowledge management. 

While NTSB has recently made progress in following leading management 

practices, its overall record in following such practices is mixed. As 

illustrated in figure 5, NTSB minimally follows leading practices in 

strategic planning, IT, and knowledge management. In the areas of human 

capital management, communications, acquisition management, and 

financial accountability and control, it partially follows leading practices. 

Much of NTSB’s progress toward following leading practices is due to 

recent management initiatives. However, NTSB lacks a human capital plan

that includes strategies on staffing, training, diversity management, and 

recruitment and retention; a comprehensive strategic plan; a knowledge 

management plan; and an IT management process. In May 2006, based on

our preliminary work, we made recommendations to NTSB to address 

some of these areas. (App. II lists our previous recommendations.) 

Leading Management 

Practices

NTSB Has Made 

Recent Progress in 

Following Leading 

Management 

Practices, but Overall 

Record Remains 

Mixed 

 15GAO-06-801T. 

Page 15 GAO-07-118 National Transportation Safety Board
Figure 5: Extent to Which NTSB Follows Leading Practices in Selected Management

Areas 

Leading practices are mostly followed

Leading practices are partially followed

Leading practices are minimally followed

Management area Extent to which leading practices followed

Source: GAO analysis of NTSB information.

Strategic planning

Human capital management

Communications

Financial accountability and control

IT

Knowledge management

Acquisition management

NTSB’s Strategic Plan 

Lacks Certain 

Performance-Based 

Elements 

NTSB’s strategic plan minimally follows leading performance-based 

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

agencies risk delivering programs and services that may not meet the 

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

Act of 1993 (GPRA)16 and guidance contained in the Office of Management 

and Budget Circular A-11, provide performance-based strategic planning

guidelines. GPRA requires federal agencies, including NTSB, to develop

strategic plans in which they define their missions, establish resultsoriented goals, and identify the strategies that will be needed to achieve 

those goals. Such a plan can help to directly link efforts such as training to

the organization’s strategic goals and help to ensure that the skills and 

competencies of its workforce enable the organization to perform its 

mission effectively. To its credit, in December 2005, NTSB issued a 

strategic plan for fiscal years 2006 through 2010, which was the first time 

 16Pub. L. No. 103-62. 

Page 16 GAO-07-118 National Transportation Safety Board
the agency had a strategic plan in 6 years. We compared NTSB’s strategic 

plan with selected elements required by GPRA. (See fig. 6.) 

Figure 6: Extent to Which NTSB’s Strategic Plan Follows GPRA Elements 

GPRA elements Follows GPRA elements

Source: GAO analysis of NTSB information.

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

5-year time frame

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, and 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. In May 2006, we 

recommended that NTSB revise its strategic plan.

17 In response to our 

recommendation, NTSB hired a contractor to assist in revising the 

strategic plan. The statement of work for the contract called for a more 

comprehensive and results-oriented plan that included the GPRA elements 

that are missing or incomplete in the current plan. As of October 2006, the 

 17GAO-06-801T. 

Page 17 GAO-07-118 National Transportation Safety Board
first draft of the revised plan had been prepared. NTSB expects to issue 

the new plan in January 2007. 

NTSB Is Partially 

Following Leading Human 

Capital Practices 

Federal agencies are experiencing pervasive human capital challenges in

acquiring and developing staffs to meet current and emerging agency 

needs. Human capital management consists of several key management 

elements, including workforce planning; performance management; 

training; recruiting, hiring, and retention; and diversity management. As 

illustrated in figure 7, NTSB is partially following leading practices in 

workforce planning; performance management; and recruiting, hiring, and 

retention and is minimally following leading practices in training and 

diversity management. 

Figure 7: Extent to Which NTSB Follows Leading Practices in Selected Human

Capital Management Areas

Leading practices are mostly followed

Leading practices are partially followed

Leading practices are minimally followed

Human capital area Extent to which leading practices followed 

Source: GAO analysis of NTSB information.

Workforce planning

Performance management

Training

Diversity management

Recruiting, hiring, and retention

NTSB is partially following leading practices in workforce planning. NTSB 

developed a draft agencywide staffing plan in December 2005 that follows 

several leading practices but lacks other leading practices such as a 

workforce deployment strategy that considers the organizational structure 

and its balance of supervisory and nonsupervisory positions. Existing 

strategic workforce planning tools and models suggest that certain 

principles should be followed in strategic workforce planning, such as 

NTSB’s Staffing Plan Is a Step 

in the Right Direction for 

Workforce Planning, but the 

Organizational Structure Has 

Not Been Reviewed 

Page 18 GAO-07-118 National Transportation Safety Board
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. Further, in workforce deployment, it is 

important to have human capital strategies to avoid excessive 

organizational layers and to properly balance supervisory and

nonsupervisory positions. NTSB’s draft staffing plan addresses the 

agency’s skills and competencies needs and includes strategies to deal 

with workforce shifts. For example, the draft staffing plan 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. Employee input provides greater assurance that new policies are 

accepted and implemented because employees have a stake in their 

development. 

NTSB is partially following leading practices in performance management. 

In prior work, we 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.18 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. NTSB has a 

comprehensive performance management plan for Senior Executive 

Service employees that links individual performance to strategic goals. 

This 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. 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.

Furthermore, 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 resultsoriented goals in the strategic plan itself, neither of the two performance 

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

fully articulated in the strategic plan, it may be difficult for staff to know 

whether their performance contributes to meeting those goals. As with the 

Performance Management 

Plans Closely Follow Leading 

Practices but Are Not Fully 

Functional 

 18GAO, Results Oriented Cultures: Creating a Clear Linkage between Individual

Performance and Organizational Success, GAO-03-488 (Washington, D.C.: Mar. 14, 2003).

Page 19 GAO-07-118 National Transportation Safety Board
2005 strategic plan, NTSB staff were not involved in the development of 

the performance plan, and there was no mechanism for employee 

feedback after the plan was initially developed. 

NTSB is minimally following leading practices in training, which is another 

key area of human capital management. It is important for agencies to 

develop a strategic approach to training their 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.19 NTSB has neither developed a 

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

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

Although NTSB staff annually identify training to improve individual 

performance, as a result of not having a core curriculum that is linked to 

core competencies and the agency’s mission, 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. We 

recommended that NTSB develop a strategic training plan.20 In response, 

NTSB plans to hire a training officer and begin addressing this 

recommendation. 

NTSB Lacks a Strategic 

Approach to Training Staff 

NTSB is partially following leading management practices for recruitment 

and retention. People are an agency’s most important organizational asset. 

With the increasing numbers of employees retiring and the numbers of 

employees who will be eligible to retire in the near future, along with 

competition from private companies, federal agencies are in a struggle to 

recruit and retain highly skilled employees. To deal with the challenges in 

acquiring and developing staffs to meet current and emerging agency 

needs, we have reported that agencies need effective human capital 

flexibilities to assist them.21 In broad terms, human capital flexibilities 

represent the policies and practices that an agency has the authority to 

implement in managing its workforce to accomplish its mission and 

NTSB Uses Flexibilities to 

Recruit and Retain Staff, but 

Strategic Recruiting and 

Succession Planning Is Lacking 

 19GAO, Human Capital: A Guide for Assessing Strategic Training and Development

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

20GAO-06-801T. 

21GAO, Human Capital: Effective Use of Flexibilities Can Assist Agencies in Managing 

Their Workforces, GAO-03-2 (Washington, D.C.: Dec. 6, 2002). 

Page 20 GAO-07-118 National Transportation Safety Board
achieve its goals. The tailored use of such flexibilities for acquiring, 

developing, and retaining talent is an important cornerstone of our model 

of strategic human capital management, which we issued to assist in 

transforming agencies so they become more results-oriented, integrated, 

and externally focused.22 We have reported that agencies find work-life 

policies and programs, such as alternative and flexible work schedules, 

transit subsidies, child care assistance, and employee assistance programs, 

to be the most effective human capital flexibilities available in federal 

agencies for managing the workforce to achieve agency missions and 

accomplish agency goals. Other effective flexibilities include monetary 

recruitment and retention incentives, student employment and 

outstanding scholar programs, and performance incentives or time-off 

awards. 

NTSB has implemented several flexibilities—such as alternative work 

arrangements, recruiting and relocating bonuses, and performance 

incentives and awards—to assist with recruiting and retention. 

Furthermore, NTSB employees are eligible to participate in federal transit 

fare subsidies and flexible spending account programs. NTSB also offers 

employees health and wellness services and health club fee 

reimbursements. We recognize that agencies need to be able to identify 

and select the recruitment and retention incentives that are most 

appropriate and effective. For instance, we have reported that student 

loan repayment programs show promise as effective tools for attracting

and retaining the talent needed to sustain the federal workforce.23

Although NTSB does not have such a program, NTSB employees can be 

reimbursed—based on funds availability—for completed university 

courses related to their current position. NTSB has also established 

student and internship programs for investigative, technical, 

administrative, and professional functions where participants are often 

converted to permanent appointments. These kinds of programs and 

opportunities help attract and retain talent in an agency. 

As mentioned earlier in this report, NTSB’s staffing plan is a step in the 

right direction for workforce planning purposes, but strategic workforce 

 22GAO, A Model of Strategic Human Capital Management, GAO-02-373SP (Washington,

D.C.: Mar. 15, 2002). 

23GAO, Federal Student Loan Repayment Program: OPM Could Build on Its Efforts to 

Help Agencies Administer the Program and Measure Results, GAO-05-762 (Washington,

D.C.: July 22, 2005). 

Page 21 GAO-07-118 National Transportation Safety Board
planning is also needed to attract and retain employees with the skill sets 

the agency needs to achieve its mission. NTSB does not have a strategic 

recruiting and retention policy. NTSB does have a recruitment and 

relocation bonus policy and a newly established policy for candidate 

selection, but these policies are limited in scope and do not align key skill 

sets with agency’s strategic goals. Furthermore, NTSB does not have any

succession plans. The Federal Workforce Flexibility Act of 2004 requires 

the head of each agency to establish, in consultation with the Office of 

Personnel Management (OPM), a comprehensive management succession 

program to provide training for employees and develop future managers 

for the agency.24 We have reported that leading organizations use 

succession planning as a strategic planning tool that focuses on current 

and future needs and develops pools of high-potential staff in order to 

meet the organization’s mission over the long term.25 Succession planning 

is used to help the organization become what it needs to be, rather than 

simply to recreate the existing organization. Also, given the retirement 

projections for the federal government that could create vacancies, 

agencies can use succession planning as a critical tool in their efforts to 

enhance diversity in their leadership positions. 

Retention is important for an agency, such as NTSB, where employees 

have unique skill sets that cannot be easily replaced. When employees 

leave an agency, a formal exit interview process allows agency officials to 

obtain detailed, firsthand information on employees’ reasons for 

separation that would allow management to analyze and address issues 

that could affect retention and take appropriate follow-up actions, such as 

improving training, career development opportunities, and 

communication. NTSB does not conduct exit interviews with departing 

employees. 

NTSB is minimally following leading practices in diversity management. 

We have reported that a high-performing organization relies on a dynamic 

workforce with the requisite talents, multidisciplinary knowledge, and upto-date skills to ensure that it is equipped to accomplish its mission and 

NTSB Is Not Following Most 

Diversity Management Leading 

Practices 

 24NTSB is required, under the Federal Workforce Flexibility Act (5 U.S.C. § 4121), to

establish a comprehensive management succession program. NTSB’s board members, as

presidential appointees, are exempt from this requirement. OPM has not yet promulgated 

required regulations under this act, and NTSB has yet to develop its program. 

25GAO, Human Capital: Selected Agencies Have Opportunities to Enhance Existing 

Succession Planning and Management Efforts, GAO-05-585 (Washington, D.C.: June 30, 

2005). 

Page 22 GAO-07-118 National Transportation Safety Board
achieve its goals.26 Such organizations provide both accountability and 

fairness for all employees and draw on the strengths of employees at all 

levels and of all backgrounds. Diversity management is a process intended

to create and maintain a positive work environment where the similarities 

and differences of individuals are valued, so that all can reach their 

potential and maximize their contributions to an organization’s strategic 

goals and objectives. We identified nine leading practices for diversity 

management. (See fig. 8.) 

Figure 8: Leading Practices in Diversity Management

Source: GAO.

1. Commitment to diversity as demonstrated and communicated by an 

organization’s top leadership

2. The inclusion of diversity management in an organization’s strategic plan 

3. Diversity linked to performance, making the case that a more diverse and 

inclusive work environment could help improve productivity and individual and 

organizational performance 

4. Measurement of the impact of various aspects of a diversity program 

5. Management accountability for the progress of diversity initiatives

6. Succession planning 

7. Recruitment 

8. Employee involvement in an organization’s diversity management 

9. Training for management and staff about diversity management

Leading Diversity Management Practices

NTSB minimally follows identified leading diversity management 

practices. For example, NTSB has not integrated diversity management 

into its strategic plan. As required, NTSB submitted its annual status 

reports to the U.S. Equal Employment Opportunity Commission in fiscal 

years 2004 and 2005 including some recruiting objectives.27 NTSB also 

 26GAO, Diversity Management: Expert-Identified Leading Practices and Agency 

Examples, GAO-05-90 (Washington, D.C.: Jan. 14, 2005). 

27Federal agencies are to report annually to the Equal Employment Opportunity 

Commission on their progress in establishing and maintaining continuous programs of 

equal employment opportunity, including workforce data collected and analyzed by race, 

gender, national origin, and disability; a description of identified barriers to equal 

employment opportunity; and a plan for eliminating or moderating such barriers. 

Page 23 GAO-07-118 National Transportation Safety Board
submitted a Federal Equal Opportunity Recruitment Program Report to 

OPM for fiscal year 2006 that highlights some proposed actions for future 

hiring.28 For instance, the NTSB report proposes to target recruiting to 

disabled veterans, women, and minority professional organizations such 

as the Organization of Black Airline Pilots, the National Society for Black 

Engineers, and the Society for Hispanic Engineers. NTSB’s report also 

calls for distribution of information to managers regarding recruitment 

sources such as internship and scholarship programs. The report states 

that NTSB will determine the feasibility of cooperative agreements with 

universities with large percentages of minority students. However, there

are no deadlines tied to these proposed actions, and accountability for 

activities is not assigned. As mentioned above, NTSB does not have any 

succession plans and is, therefore, not using that process to assist with 

diversity management. NTSB also lacks a formal mentoring program and 

does not have advisory groups to foster employee involvement in diversity 

management. 

Communications from 

Senior Management to 

Staff Have Increased, but 

Upward Communications 

Mechanisms Are Lacking 

NTSB is partially following leading 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.29 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 they communicate 

information to staff. For example, the Managing Director periodically 

sends “management advisory” e-mails 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 confidential employee 

surveys; or incorporated employee feedback into policy making. 

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. In May 2006, we recommended that NTSB 

 28Agencies are required to report annually to OPM concerning their Federal Equal 

Opportunity Recruitment Program, which is a program established by Congress and 

overseen by OPM to ensure equal employment opportunity in recruitment.

29GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers and

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

Page 24 GAO-07-118 National Transportation Safety Board
develop mechanisms that will facilitate communications from staff-level 

employees to senior management.30 In response to this recommendation, 

NTSB has begun developing a communications plan. The agency has also 

begun activities to enhance communication from staff to management, 

such as outreach visits to regional offices and brown bag lunches with 

senior managers and board members. In addition, the agency conducted a 

survey in September 2006 to obtain employee input on its revised strategic

plan. According to agency officials, although they have no set schedule for

regional office visits and employee surveys, their goal is to continue the 

visits on an ad hoc basis and the survey on an as needed basis for specific 

purposes, such as to obtain more detailed, actionable information to 

followup on OPM’s biennial employee survey. 

Acquisition Management 

Has Made Significant 

Progress in Recent Years 

NTSB is partially following leading acquisition practices that promote an 

efficient and accountable acquisition environment and process. We found 

that leading organizations transform the acquisition function from one 

focused on supporting various business units to one that is strategically 

important to the bottom line of the whole organization. For example, 

NTSB has a Chief Acquisition Officer and is, for the most part, strategically

assessing acquisition needs. After NTSB identified weakness in its small 

purchases program, audits by both GAO and DOT IG in the early 2000’s 

identified weaknesses in the agency’s financial internal controls.31 As a 

result of these audits, NTSB undertook a number of initiatives to improve 

its acquisition activities. For example, NTSB established an Acquisition 

Division in October 2003 and hired an individual to manage the agency’s 

acquisition program and to implement the GAO and DOT IG 

recommendations. In addition, NTSB’s purchase card program was 

transferred to the Acquisition Division in fiscal year 2005. Upon assuming 

responsibility for this program, the division developed and implemented 

new purchase card policies and procedures. As part of these new 

procedures, the approving administrative officers at headquarters are 

responsible for purchasing office supplies and services for the agency, as 

needed, while investigators who hold purchase cards are limited to using 

 30GAO-06-801T. 

31DOT IG, National Transportation Safety Board: Rapiddraft Payment System, Statement 

of Kenneth M. Mead Before the Budget Committee Task Force on Housing and 

Infrastructure, U.S. House of Representatives, April 13, 2000; GAO, National 

Transportation Safety Board: Weak Internal Control Impaired Financial Accountability, 

GAO-01-1032 (Washington, D.C.: Sept. 28, 2001). 

Page 25 GAO-07-118 National Transportation Safety Board
them only on the scene of an accident during an investigation. NTSB also 

instituted a purchase limit for all staff. The single purchase limit is $2,500, 

and the monthly cycle-limit for purchases cannot exceed $25,000. NTSB 

also required that all purchase card holders and approving officials take an 

online General Services Administration (GSA) training course and 

additional NTSB training. Other controls to protect against fraud, waste, 

and abuse include certifying funds and obtaining approval from the 

cardholder’s supervisor prior to making a purchase.32 In addition, the 

cardholder’s approving official reviews and approves cardholders’ monthly 

statements. NTSB also performs random audits of cardholders’ purchase 

card files to ensure that procedures are being adhered to. However, due to

lack of staff in the 10 regional offices, the Acquisition Division has not 

randomly audited these purchase card holders. According to NTSB 

officials, they mitigate the risk associated with the lack of these audits by 

having the Chief Financial Officer (CFO) and the responsible approving 

official review all purchase card activity via the monthly Citibank 

transaction reports. However, unlike an audit, such a review does not 

assure that acquisition procedures are being followed. 

Throughout the acquisition process, leading management practices have 

shown financial information should be tracked and communicated in a 

way that enables effective evaluation and assessment of acquisition 

activities. When financial data are not useful, relevant, timely, or reliable, 

the acquisition function—as well as other functions across an 

organization—are at risk of inefficient or wasteful business practices. 

NTSB is partially following this practice. For example, NTSB’s purchase 

card program requires administrative and other key purchase card users to 

obtain quarterly lump sum funds approvals called credit authorizations. 

Once these cardholders have an approved credit authorization, they must 

prepare and submit to their supervisor a “credit buy” for every purchase.

According to NTSB’s purchase card procedures, a purchase cannot be 

made until funds have been certified, and a supervisor has approved the 

purchase. NTSB tracks and monitors both credit authorizations and credit 

buys using the Interior Department Electronic Acquisition System (IDEAS) 

Procurement Desktop, a Windows-based acquisition software application

intended to facilitate the purchasing of goods and services. The program 

 32Other positive steps taken by the Acquisition Division include providing monthly 

obligations reports to all office directors and focusing on customer outreach and 

education. The Acquisition Division has also hosted training classes for senior staff, 

administrative staff, and its Contracting Officer’s Technical Representative to educate them

on their responsibilities in the acquisition process.

Page 26 GAO-07-118 National Transportation Safety Board
automates the entire purchasing process from creation of the purchase 

request to contract closeout. However, IDEAS cannot alert managers to 

identify when quarterly credit authorizations are running low and, 

therefore, there is a potential that more money can be spent than allotted.

NTSB mitigates this risk by reviewing all purchases monthly. 

Effective acquisition planning for IT includes having a written

organizational policy guiding acquisitions and an acquisition strategy that

includes objectives, projected costs and schedules, and risks and 

addresses the entire project life cycle. NTSB is not using some key 

processes and capabilities needed to successfully handle IT acquisitions. 

Sound business practices call for agencies to establish acquisition policies

for IT to institutionalize and guide activities, such as project planning, to 

include budgeting and scheduling, requirements management, and risk 

management.33 NTSB does not have an agencywide policy specific to IT 

acquisitions, which increases the risk that NTSB will not be able to 

effectively manage new IT programs as they are acquired and come online. 

Other leading management practices in acquisition include strategically 

assessing the agency’s needs and developing acquisition approaches to 

help the agency meet those needs, as well as leveraging the purchasing 

volume by identifying agencywide acquisitions of goods and services. In 

August 2004, Booz Allen Hamilton recommended that NTSB consolidate 

the purchasing of office supplies, uniforms, and other equipment in order 

to gain efficiencies such as acquiring quantity discounts, allowing 

spending to be easily tracked, tracking supply usage and forecasting needs 

with ease, and accounting for office purchases. In response to this 

recommendation, NTSB now centrally purchases computers, copiers, 

protective equipment, and uniforms.34 NTSB has also assessed and 

incorporated changes to enable its acquisition process to better respond to 

 33Carnegie Mellon University’s Software Engineering Institute, recognized for its expertise 

in software and system processes, has developed the Capability Maturity Model® 

Integration (CMMIsm) and a CMMI appraisal methodology to evaluate, improve, and manage 

system and software development processes. The CMMI model and appraisal methodology

provide a logical framework for measuring and improving key processes needed for 

achieving quality software and systems. 

34NTSB’s Acquisition Division processes approximately $10-12 million per year on contracts 

that include approximately 600 small acquisition actions that total under $100,000 per year. 

The division also processes contracts for NTSB’s training center that usually amount to

under $100,000 per year. 

Page 27 GAO-07-118 National Transportation Safety Board
unforeseen external events and emergencies.35 For example, NTSB was 

granted “special contracting authority” in the NTSB Reauthorization Act of

2003 to help it award contacts without competition in order to expedite 

accident investigations. Since the authority was granted, NTSB has used it 

11 times for a total acquisition value of $98,744. This is compared with 

$8,110,165 in total contract award dollars in fiscal year 2004 and 

$10,482,001 in total contract award dollars in fiscal year 2005. NTSB also 

has an appropriated emergency fund of $2 million, which is used for 

acquisitions.36 The emergency fund provides additional resources if NTSB 

requires additional funding during the course of an investigation to 

purchase products or services. NTSB has used this authority selectively. 

For example, in the last 8 years, NTSB has accessed the fund once in fiscal 

year 2002 for costs related to the crash of American Airlines flight 587 at 

Belle Harbor, New York, and, at that time, the disbursement was about a 

quarter of the fund or $491,687. 

NTSB Follows Certain 

Leading Practices in 

Financial Management but 

Lacks a Full Cost 

Accounting System and Is 

Not Compliant with the 

Anti-Deficiency Act 

NTSB is partially following leading practices in financial accountability 

and control. A key to financial accountability is obtaining accurate and 

useful information on a timely and ongoing basis to support day-to-day 

managerial decisions and oversight. Other financial leading management 

practices include clear, strong financial management leadership by 

establishing the CFO position with specific authority and functional 

responsibilities for improving financial management, conducting related

long-range planning, preparing agencywide financial statements that are

subject to independent audit and preparing an agencywide public 

accountability report. NTSB’s CFO has emphasized the importance of 

sound financial management based on best practices and has taken an 

active role in managing internal controls and improving financial 

management. For example, the CFO oversees the monitoring and financial 

execution of the agency budget in relation to actual expenditures and 

reports this information via weekly reports and regular senior

management meetings. The CFO also provides information and regular 

communication to program office administrative officers and attends 

program office meetings. NTSB also has an arrangement with the 

 35For example, NTSB has prepared annual procurement forecasts since fiscal year 2004 to

assist the agency with planning and gaining efficiencies. 

36Based on information from the Managing Director, CFO, and the respective modal 

director, the Chairman makes the decision to make the emergency fund available for 

extraordinary accident investigation costs. 

Page 28 GAO-07-118 National Transportation Safety Board
Department of Interior for personnel, payroll, accounting, and contracts 

and procurement systems. This arrangement allows the CFO to provide 

relevant financial and performance information to agency decision 

makers. Similar to private sector companies, government agencies are 

required to report their financial condition in publicly available financial 

statements. NTSB received an unqualified or “clean” opinion from 

independent auditors on its financial statements for the fiscal years ending

September 30, 2003 through 2006. The audit reports 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 those 4 fiscal years. 

While cost accounting systems37 provide financial information that can be

used to monitor ongoing operations, they also aid in planning for the 

future. We have reported that sound financial management is crucial for 

responsible stewardship of federal resources.38 In 2000, RAND 

recommended that NTSB develop systems that would allow the agency to

better manage its resources by permitting full-cost accounting of all 

agency activities and recommended this be completed within a year.39 To 

accomplish this, RAND recommended putting in place a timekeeping 

system, in which individual project numbers were assigned to each 

investigation and support activity 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 began 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 

 37Cost 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. 

38GAO, Executive Guide: Creating Value through World-class Financial Management, 

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

39RAND Institute for Civil Justice, Safety in the Skies: Personnel and Parties in NTSB 

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

Page 29 GAO-07-118 National Transportation Safety Board
manage staff workloads properly” remains current. An NTSB official 

stated that a major challenge will be the cultural change to use the cost 

accounting system once installed because of the size of NTSB; some 

divisions only have 10-20 investigators, and the official stated that the 

division managers know the workload of each investigator. In May 2006, 

we recommended that NTSB develop a full cost-accounting system. NTSB 

agreed with the recommendation and told us that it will attempt to allocate 

funds in fiscal year 2007 to address this capability. 

Finally, 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 training center lease obligation at the time the lease 

agreement was signed in 2001. This occurred as a result of NTSB 

classifying the lease as an operating lease rather than a capital lease. 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 Anti-Deficiency Act violation by inserting an 

amendment in its fiscal year 2007 appropriation that would allow NTSB to 

fund this obligation from its salaries and expense account through fiscal 

year 2020. However, this proposal was removed once the budget went to

the House and Senate Appropriations Committees and, at this time, leaves 

the Anti-Deficiency Act violation uncorrected. If this provision is not 

passed, NTSB will need to take action to correct the Anti-Deficiency Act 

violation. This could include obtaining a deficiency appropriation for the 

full amount of the lease, renegotiating, or terminating the lease so that it 

complies with the Anti-Deficiency Act, or obtaining authority to obligate 

lease payments using annual funds. 

NTSB Is Making Progress 

in IT Management but Still 

Lacks Key Components 

NTSB has made improvements in its IT program, but weaknesses persist. 

Federal agencies are increasingly relying on IT to facilitate mission 

support. Our previous work has identified key elements of an IT program, 

which include an IT strategic plan, enterprise architecture, IT investment 

management, and information security. At present, NTSB is minimally 

following leading IT management practices. Currently, NTSB does not 

have a strategic management plan for IT, and it has not developed an 

enterprise architecture plan for modernizing its IT systems. Similarly, 

NTSB also lacks an IT investment management process to control and 

evaluate the agency’s IT investment portfolio. Additionally, in 2005, the 

DOT IG found significant weaknesses in NTSB’s information security 

Page 30 GAO-07-118 National Transportation Safety Board
program and reported that NTSB computers were vulnerable to 

unauthorized access from both inside and outside the agency and that the 

agency had no system to identify security breaches on its network.40

NTSB has made some improvement to IT security in response to DOT IG 

recommendations. To manage information security risks, NTSB has 

instituted a program of intrusion detection and computer vulnerability 

scanning. NTSB has also invested in advanced training for IT staff on 

information security and has trained all users of the agency’s computer 

system in computer security awareness. Furthermore, NTSB has created a 

Chief Information Officer (CIO) position, which will be responsible for IT. 

Although NTSB is actively recruiting for the position, it is still vacant.41

However, NTSB has recently hired a deputy CIO who has expertise in 

enterprise architecture and IT investment management. Nonetheless, in 

October 2006, the DOT IG found that while NTSB has made a concerted 

effort to improve its information security program, its program still has 

significant deficiencies.42

NTSB Lacks a Knowledge 

Management Program 

NTSB is minimally following leading practices in knowledge management. 

Knowledge management includes four fundamental principles: leadership

that articulates management’s vision and goals (e.g., in written policies 

and guidance), processes (including performance measurements) to turn 

vision into reality, technology that allows implementation of goals and 

supports the processes, and a culture of knowledge sharing and reuse. 

Knowledge management is essential to an organization because it is a 

means by which people create and share knowledge, including data and 

information. Some key elements of knowledge management are having an

agencywide knowledge management initiative and having a senior official 

who coordinates this initiative and integrates it with other areas of the 

organization. Although the 2004 OPM’s Federal Human Capital Survey 

reported that over 90 percent of NTSB employees were satisfied with the 

use of IT to gather and share knowledge, NTSB does not have a knowledge 

 40DOT IG, Information Security Program: National Transportation Safety Board, FI2006-001 (Washington, D.C.: Oct. 7, 2005). 

41When the position becomes filled, NTSB expects that the CIO will focus upon maintaining

the NTSB desktop computer program, refreshing and consolidating some computer

servers, and improving technical resources for continuity of operations.

42DOT IG, Information Security Program: National Transportation Safety Board, FI2007-001 (Washington, D.C.: Oct. 13, 2006). 

Page 31 GAO-07-118 National Transportation Safety Board
management initiative or program and lacks a CIO to implement policies 

and procedures on information sharing. 

NTSB has an accident investigation process in which some transportation 

modes have detailed criteria for determining which accidents to 

investigate, while others do not. Although accident investigations are 

sometimes lengthy, NTSB takes steps to ensure that recommendations for 

improving transportation safety are made available to the transportation 

industry before a report is issued. To assist in accident investigations, 

NTSB employs the use of outside sources that provide technical expertise.

Also, public hearings are used to assist in the investigation process, 

although they are time and resource intensive. Finally, NTSB proactively 

accomplishes its mission by conducting public forums and safety studies. 

NTSB accomplishes its transportation safety function by conducting onscene investigations of selected accidents in all transportation modes. 

Since its inception in 1966, NTSB has investigated over 134,000 

transportation accidents, over 90 percent of which were aviation. NTSB’s 

statutory mandate gives it broad discretion in determining which accidents

in the nonaviation modes to investigate. Since NTSB lacks the staff 

resources to conduct on-scene investigations of all aviation accidents or a 

large number of nonaviation accidents, certain modal offices have adopted 

additional risk-based guidance for selecting accidents for investigation. 

Figure 9 describes the legislative and other criteria that NTSB uses to 

identify accidents to investigate. 

NTSB Carries Out Its 

Transportation Safety 

Function by 

Investigating 

Accidents, Issuing 

Recommendations, 

and Taking Proactive 

Steps Outside of 

Specific Accidents 

NTSB’s Use of Risk-Based 

Criteria to Select 

Accidents to Investigate is 

Uneven 

Page 32 GAO-07-118 National Transportation Safety Board
Figure 9: Legislative, Regulatory, and Other Criteria for Identifying Accidents to Investigate, by Mode

Investigates or causes to be investigated all civil and certain 

public aircraft accidents in the United States and participates

in the investigation of international accidents where the 

United States is the state of registry, operator, designer, or 

manufacturer.

Investigates international or domestic accidents where 

there is the likelihood of significant public interest or 

involvement of individuals of national prominence. 

Investigates selected accidents including railroad grade 

crossing accidents, which NTSB selects in cooperation with 

a state.

Investigates pipeline accidents in which there is a fatality, 

substantial property damage, or significant injury to the 

environment.

Identifies candidate accidents for investigation using a 4-tier 

system: 

Tier 1: general accidents that have five or more fatalities

and mostly involve passenger vehicles. 

Tier 2: accidents that have two or more fatalities or one or 

more of varying circumstances.

Tier 3: accidents that have one fatality and one or more of 

varying circumstances.

Tier 4: any accident not in tiers 1, 2, or 3 that might have 

significant safety issues; any accident in any other mode, 

when the accident is reported to that mode’s duty officer.

Investigates railroad accidents involving a fatality, substantial 

property damage, or a passenger train.

None.

None.

Investigates releases of hazardous materials in any mode that 

involves a fatality, substantial property damage, or significant 

injury to the environment. For all modes, NTSB also evaluates

the adequacy of safeguards and procedures for the 

transportation of hazardous materials and the performance of 

other departments, agencies, and instrumentalities of the 

government responsible for the safe transportation of that 

material.

None.

Aviation 

Highway

Railroad

Pipeline 

Hazardous materials

Investigates selected major accidents and incidents, collisions

involving public vessels with any nonpublic vessel, accidents

involving significant safety issues related to Coast Guard safety 

functions, and international accidents within the territorial seas

and where the United States is the state of registry. 

Major marine accidents are defined as a casualty that results in 

(1) the loss of six or more lives; (2) the loss of a mechanically 

propelled vessel of 100 or more gross tons; (3) property 

damage initially estimated as $500,000 or more; or (4) serious

threat, as determined by the Commandant of the Coast Guard 

and concurred with by the Chairman of NTSB, to life, property, 

or the environment by hazardous materials.

Investigates accidents involving the risk to the safety of 

third parties, such as passengers or port facilities; serious

threats to life, property, or the environment; and a vessel 

collision with one or more fatalities or $75,000 or more in 

property damage.

Marine

Mode Legislative and regulatory criteria Additional guidance

Source: GAO analysis of legislative, regulatory, and NTSB documents.

NTSB allocates most of its staff resources to conduct a significant number 

of aviation accident investigations. As mentioned earlier in this report, 

NTSB is required by statute to investigate all domestic civil aviation 

Page 33 GAO-07-118 National Transportation Safety Board
accidents and certain other aviation accidents. However, in 2004, citing a 

severe shortage of regional investigators, the Office of Aviation Safety 

issued a memorandum to investigators intended to manage its aviation 

workload due to the shortage of aviation investigators. The memorandum 

calls for, among other things, more selectivity in which accidents to 

investigate on-scene in order to minimize investigative efforts on accidents 

in which there is minimal safety “payback,” equalize regional workloads, 

and reassign some accidents to NTSB headquarters for investigation. Even

with this guidance, the number of NTSB’s staff that investigates aviation 

accidents may limit the resource amounts that NTSB can use to investigate 

accidents in other modes, especially rail, which may have broader or more 

critical safety implications, which we discuss later in this report. 

In addition, NTSB investigates general aviation and small aircraft 

accidents that are also investigated by FAA. In some cases, NTSB uses 

FAA investigators and inspectors to leverage its resources.43 NTSB’s size 

prevents it from being on-site for many general aviation investigations; 

therefore, the agency conducts “desk investigations” in which NTSB 

investigators do not go to the scene of the accident to gather information 

but rather correspond with FAA by mail, e-mail, or phone to gather 

information and conduct analyses. 

As with the aviation mode, NTSB is also mandated to investigate certain 

types of transportation accidents in nonaviation modes. NTSB has orders 

or guidelines that define the safety program for each mode and identify the 

types of accidents that are investigated and the procedures for doing so. 

Furthermore, in an attempt to manage resources and ensure the maximum 

safety benefit, the highway office has adopted policies that are within the 

framework of the legislation and board orders and that identify and 

prioritize candidate accidents for investigation. For example, in an effort 

to ensure better use of resources, the highway office has a four-tier system 

to identify accidents for investigation based on the severity of the accident 

and the amount of property damage, among other things. This system 

provides risk-based criteria for the office to determine which of the 

approximately 6 million highway accidents each year it will investigate. In

contrast, the marine office, which investigates significantly fewer 

accidents than the highway office—in 2005, NTSB, investigated 32 

highway accidents compared with 3 marine accidents—has instituted 

 43FAA can also conduct separate investigations looking into compliance issues with federal 

aviation laws and regulations. 49 U.S.C. §40113(a). 

Page 34 GAO-07-118 National Transportation Safety Board
guidance that provides less restrictive criteria for determining which 

accidents to investigate. For example, the regulations and a memorandum 

of understanding with the Coast Guard require NTSB to investigate 

selected major marine accidents, which include casualties that result in 

the loss of six or more lives or property damage of $500,000 or more, while 

additional guidance calls for investigating accidents with one or more 

fatalities or $75,000 or more in property damage.

In contrast to the highway mode, NTSB does not have documented, riskbased criteria for selecting rail, pipeline, and hazardous materials 

accidents to investigate. Board orders for these modes contain the 

statutory language for selecting accidents to investigate but no further 

criteria. As a result, officials from NTSB’s rail, pipeline, and hazardous 

materials offices told us that it is difficult to determine which accidents to 

investigate given their resource constraints. They said that the number of 

investigators has decreased since 2000 and that attrition has been a 

significant problem for them because they are losing expertise. Since 2000, 

the office experienced a 16 percent decline in the number of investigators 

and technical specialists—the 37 staff filling these positions in fiscal year 

2000 dropped to 31 at the beginning of fiscal year 2007. 

As a result of not having a policy for selecting accidents in these modes, 

the agency lacks assurance and transparency that it is managing resources 

in a manner that ensures a maximum safety benefit. For example, a rail

stakeholder that we spoke with questioned why NTSB did not investigate 

four railroad accidents in 2006 that resulted in one fatality, several injuries, 

and significant property damage. Moreover, at least three of these 

accidents resulted from collisions, which they identified as a recurring 

problem in the rail industry that NTSB has placed on its “Most Wanted 

List”—which includes those safety recommendations that NTSB has 

designated as critical—meaning that changes are needed to reduce 

transportation accidents and to save lives.44 According to NTSB officials, 

safety issues that they have already identified, such as those on the “Most 

Wanted List,” are a lower priority to investigate than new safety issues. 

While this is a reasonable approach, it is not documented policy and

clearly has not been communicated to industry or the public.

 44To prevent train collisions and overspeed accidents, NTSB’s “Most Wanted List” includes

a recommendation that FRA require automatic control systems to override mistakes by 

human operators. 

Page 35 GAO-07-118 National Transportation Safety Board
In addition, while stakeholders recognize that NTSB lacks resources to 

investigate many rail accidents, they believe that NTSB most often 

investigates only large or controversial rail accidents. For example, of the 

3,191 railroad accidents that occurred in 2005, NTSB investigated 9. By 

comparison, FRA, with a staff of 435 field inspectors compared to 13 NTSB

railroad investigators, investigated 98 accidents that year. Rail

stakeholders told us that they believe that there are some “small” 

accidents with root causes and contributing factors that could have 

prevented larger accidents. While these small accidents may not result in 

great human or property loss, they may have significant safety

implications and serve as forecasts for future accidents, as well as 

providing background data to inform investigators of mitigating 

circumstances in other accidents. As a result, stakeholders are unsure why 

certain accidents are selected for investigation and believe that rail 

accident investigation criteria should be reviewed. 

NTSB Has Taken Steps to 

Reduce the Potential 

Negative Consequences of 

Lengthy Investigations 

The length of NTSB investigations can adversely impact transportation 

safety by delaying the final report and any safety recommendations. NTSB, 

recognizing that investigations are lengthy, has processes that address 

transportation safety issues before the release of a report. The initial, onscene phase of the accident investigation, and the subsequent analysis of 

evidence, has taken an average of 1.5 years (or 18 months) to complete. 

Moreover, the average duration of accident investigations has increased 

over the last 10 years. For example, in 1996 the average length of an 

investigation was 410 days, compared with 638 days in 2006. (See fig. 10.) 

Page 36 GAO-07-118 National Transportation Safety Board
Figure 10: Average Duration of Accident Investigations for Which Recommendations were Issued, Calendar Years 1996-2006

Number of days

0

100

200

300

400

500

600

700

800

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Source: GAO analysis of NTSB data.

Year

There is no specific time line for how long an accident investigation 

should take, according to NTSB; the complexity of the accident dictates 

the time frame for completing the on-scene phase of the investigation. Two 

additional factors also are likely to affect the length of accident 

investigations. First, investigators sometimes need to investigate new 

accidents before completing ongoing investigations. Second, NTSB 

managers and investigators told us that resource constraints are 

contributing factors in how they accomplish their mission. Specifically, 

rail officials said that declining numbers of investigators affect the number 

of accidents that they investigate. 

The potential negative effect of a lengthy accident investigation is that a 

full report outlining details of the accident, including probable causes and 

sometimes safety recommendations, is not issued until the completion of 

the investigation. In certain cases, this may hinder transportation safety as

recommendations for improvements may be delayed until the report is 

issued. However, NTSB employs two tools to help ensure transportation 

safety in this instance. First, NTSB can issue safety recommendations 

before a report is issued. NTSB designates priority recommendations as 

“urgent.” Since 2001, the agency has issued 26 urgent recommendations, of

Page 37 GAO-07-118 National Transportation Safety Board
which 6 have been implemented.45 An urgent recommendation outlines 

immediate actions for the transportation industry to take to prevent 

impending loss or damage due to a similar accident. For example, NTSB 

issued urgent recommendations to the Northeast Regional Commuter 

Railroad Corporation to install an automatic train control system and to 

the Washington Metropolitan Area Transit Authority to provide written 

instructions for identifying and responding to emergency train rollback 

situations. Second, during the course of an investigation, investigators can

also issue suggestions for improvements that can be addressed to a variety 

of entities such as states, private organizations, or manufacturers. Once 

these suggestions have been implemented, they then become safety 

accomplishments. Since fiscal year 2001, NTSB has issued 256 safety 

accomplishments, of which over 90 percent have been in the aviation 

mode. 

External Sources Provide 

Essential Services during 

Accident Investigations 

Outside experts provide critical assistance to NTSB investigators 

throughout the on-scene phase of an investigation. During the course of an

investigation when additional support is needed for fact finding or 

technical analysis, NTSB supplements its investigative staff through the 

use of “parties” and outside contractors.46 “Party” participants are 

individuals, agencies, companies, and associations that can provide 

technical expertise relevant to a specific accident during the fact-finding 

phase. For example, in an aviation accident, the parties to the 

investigation may include the aircraft manufacturer and operators; by 

statute, FAA is always a party to an aviation investigation. While the party

process may provide technical information that is important for 

determining the cause of an accident, it presents inherent conflicts of 

interest for entities that are both parties in an investigation and potential 

defendants in related litigation. For example, in a commercial aviation 

accident, the principal defendants in litigation for damages are likely to be

 45Of the 26 urgent recommendations, 21 were aviation, 3 were highway, and 2 were railrelated. 

46NTSB contracts with experts who deal with specific facets of the investigation for which 

NTSB does not need to retain continual expertise. For example, following an accident 

involving casualties, NTSB’s Office of Transportation Disaster Assistance, which is 

responsible for providing support to victims’ families, may contract a team of forensic 

specialists who respond to mass fatality events. These outside contractors are used by all 

modes depending upon the accident and the type of information and analysis needed. Since

2004, NTSB has contracted with 10 different companies, which provided services such as 

radiological testing, pipeline testing, and report writing, for a total cost of $282,757. 

Page 38 GAO-07-118 National Transportation Safety Board
the airline and aircraft manufacturer, who may face liability for dozens of 

deaths. In addition, both entities are likely working with NTSB as parties 

to the investigation. 

Despite such challenges, the party system appears to be working well. 

RAND found that the party system works well in that it allows NTSB to 

leverage its resources to provide critical safety information in regard to 

the accident under investigation. In addition, NTSB officials told us that 

the system is an efficient way of gathering and sharing information about 

the accident with investigators and other parties. Also, having multiple 

parties on an investigation offsets concerns of conflict of interest and 

impartiality. 

NTSB May Also Conduct 

Public Hearings During 

Investigations, Which Are 

Infrequent and Resource 

Intensive 

Although public hearings can provide useful information to NTSB 

investigators to assist in the accident investigation and define policy issues 

or emerging areas of transportation safety, they occur infrequently 

because NTSB managers view them as an inefficient use of resources. 

Public hearings are inquiries intended to supplement the facts discovered 

during the on-scene and subsequent follow-up investigation of an accident.

They are generally held with regard to a major accident in which there is

wide and sustained public interest, or significant safety issues. They are 

intended to produce comprehensive coverage of all relevant factual data

and publicly record the substance of all the evidence. Since 1997, NTSB 

has held 29 public hearings, primarily for aviation accidents (see table 3). 

Of those 29 hearings, 16 were as a result of an accident, and the other 13

were on general transportation safety issues such aviation image 

recorders47 or pipeline safety. Of the 16 accident hearings, 13 were held 

within 1 year of the accident, and the remaining 3 were held within two 

years of the accident. 

 47Aviation imaging recorders are crash-protected imaging systems often called video

recorders on aircraft used in commercial air transportation operation. 

Page 39 GAO-07-118 National Transportation Safety Board
Table 3: Number of Public Hearings by Mode, Calendar Years 1997-2006 

Year Aviation Marine

Rail, pipeline,

 and hazardous

materials Highway Total

1997 1 0 0 0 1

1998 1 1 1 2 5

1999 1 2 2 3 8

2000 2 0 1 1 4

2001 0 0 0 0 0

2002 2 0 1 0 3

2003 1 0 0 1 2

2004 1 0 0 0 1

2005 1 0 1 0 2

2006 2 0 0 1 3

Total 12 3 6 8 29

Source: GAO analysis of NTSB data. 

Note: Calendar year 2006 includes data through August 2006. 

NTSB managers have cited resource constraints as reasons for the limited 

use of public hearings. However, on occasion, board members have voted 

to hold a public hearing despite staff recommendations to the contrary. 

NTSB officials told us that the coordination and preparation of witnesses 

to testify at the hearings requires significant administrative planning and 

logistical organization and that this process can sometimes be costly, take

resources away from accident investigations, and delay reports. However, 

NTSB was not able to provide data on how much time is spent preparing 

for public hearings because it lacks a full cost accounting system. 

Nonetheless, transportation industry stakeholders felt that hearings were 

valuable for public transparency because they allowed for the parties to 

the investigation to question the witnesses. In an effort to reduce travel 

costs associated with public hearings, in 1999, NTSB began holding all 

public hearings in Washington, D.C., whereas previously hearings were 

held near the site of the accident. In addition, NTSB has also begun 

webcasting public hearings so that individuals interested in or associated

with the accident may view it without traveling to the hearing.

Page 40 GAO-07-118 National Transportation Safety Board
NTSB has a good record of making recommendations to improve 

transportation safety and having a large percentage of recommendations 

implemented. Since 1996, NTSB has issued 2,417 recommendations, of 

which 1,647 (or 68 percent) were closed. Of the closed recommendations, 

88 percent have been closed out with the agencies having taken acceptable 

or favorable action toward implementation. The remaining 12 percent of 

closed recommendations were closed out with an “unacceptable” status 

classification. NTSB uses the unacceptable classification for situations 

such as the agency not agreeing to implement the recommendation, taking

longer to implement than NTSB would like, or taking alternative action to

meet the intent of the recommendation, which NTSB finds unacceptable.

(See app. III for further information.) The recommendation acceptance 

rate for closed recommendations varies across modes—with rail having

the highest acceptance rate and marine the lowest—and the overall rate 

has remained relatively high over the last decade. (See fig. 11.) Regarding

NTSB’s open recommendations for this same time period, about 15 

percent of NTSB’s open recommendations are classified with an 

unacceptable agency response. Aviation has the highest percentage of 

open recommendations with an unacceptable response, while pipeline has 

the lowest. (See fig. 12.)

Most NTSB 

Recommendations Are 

Accepted, but Some 

Recommendations Are 

Impractical for the 

Industry to Implement 

Figure 11: Acceptance Rate by Mode, Calendar Years 1996-2006 

0

20

40

60

80

100

Aviation Highway Marine Pipeline Railroad Overall

Percentage of recommendations

Source: GAO analysis of NTSB data.

Mode

Note: Calendar year 2006 includes data through June 8, 2006. 

Page 41 GAO-07-118 National Transportation Safety Board
Figure 12: Percentage and Number of Open Recommendations with Unacceptable 

Agency Action Issued During Calendar Years 1996-2006

Mode

Number of recommendations

Source: GAO analysis of NTSB data.

0 10 20 30 40 50 60 70 80 90 100

Railroad

Pipeline

Marine

Highway

Aviation

24% of all aviation

recommendations

7% of all

highway

recommendations

15% of all

marine

recommendations

0% of all

pipeline

recommendations

9% of all

railroad

recommendations

Note: For each mode of transportation, the bar shown represents the number of recommendations 

that were open as of June 8, 2006, and have an unacceptable action status category assigned by 

NTSB. The embedded pie chart for each mode shows what percentage these unacceptable 

recommendations make up of that mode’s total number of open recommendations. Calendar year 

2006 includes data through June 8, 2006. 

Although there may be several reasons why agencies do not implement 

some NTSB recommendations, cost is a contributing factor. NTSB does 

not determine the costs associated with the benefits of a particular safety

recommendation. As a result, agencies determine that some 

recommendations are impractical for industry to implement. Some of 

those recommendations that the industry considers impractical are 

deemed of high importance to NTSB, which has placed them on its “Most 

Wanted List.” For example, a recommendation from this list that remains 

open due to an analysis of excessive cost by the FAA is to improve audio 

and data recorders on aircraft, based on an original safety 

recommendation from 1999. FAA determined that after an analysis of the 

benefits of having two systems, it was unable to justify the excessive cost 

that would be incurred in the installation of two complete systems and, 

therefore, this change has not been required by FAA. 

While cost may be an important factor for why some recommendations are 

not implemented, agencies also site redundancies that some 

recommendations may cause as a reason for disagreement with the 

recommendation. For example, in 1997, NTSB recommended that FRA 

require the recording of train crew members’ voice communications for 

Page 42 GAO-07-118 National Transportation Safety Board
use in accident investigations. However, after review, FRA found that this

recommendation was impractical because there were already devices in 

place that would better capture and preserve data that would provide 

information to investigators in an accident investigation. For this reason, 

FRA concluded that the implementation of cab voice recorders was not 

justified and did not accept this recommendation. 

The process of closing out or changing recommendations is time 

consuming and paper-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 federal agencies may be unaware of whether their 

response has been accepted or not accepted by NTSB. In our prior work, 

we recommended that NTSB improve the efficiency of the review process 

for recommendations by computerizing the documentation and 

implementing concurrent reviews. NTSB agreed with this 

recommendation and would like to replace its current process with an 

automated one. However, they stated that their ability to do this will 

depend on the availability of funds. In the meantime, in response to our 

recommendation, NTSB has created the position of Associate Managing 

Director for Quality Assurance. This individual is analyzing the manual 

review process for changing the status of recommendations and is 

expected to recommend strategies to ensure that the process is effective

and efficient, according to NTSB officials. 

NTSB Takes Proactive 

Steps Outside of Specific 

Accident Investigations 

NTSB complements its accident investigation activities through 

supplemental tools that are not necessarily a part of the accident 

investigation process. Safety studies, public forums, and symposia are 

mechanisms that NTSB uses to gather further information on 

transportation safety. Safety studies consist of research undertaken by 

NTSB on safety issues that may be relevant to more than one accident. 

They are intended to provide improvements in transportation safety by 

affecting changes to policies, programs, and activities of agencies that 

regulate transportation safety. Safety studies also allow NTSB to assess 

and reassess techniques and methods of accident investigation and may 

result in recommendations to reduce the likelihood of recurrence of 

transportation accidents. Since 2000, NTSB conducted four safety studies. 

(See table 4.) The four studies resulted in 41 recommendations addressed 

to FAA and PHMSA. For example, in a 2005 study of risk factors 

associated with general aviation accidents, NTSB recommended that FAA 

revise guidance material associated with pilot weather briefings to include 

guidance on applicable sources of weather information, such as the 

Internet and satellites; NTSB also recommended that FAA develop a 

Page 43 GAO-07-118 National Transportation Safety Board
means to identify pilots whose overall performance history indicates that 

they are at future risk of accident involvement and develop a program to 

reduce risk for those pilots. Industry stakeholders told us they would like 

NTSB to conduct more safety studies, which they believe address NTSB’s 

mission in a more proactive way. For the most part, safety studies are 

initiated at the request of NTSB staff, and recent studies have taken 

between 1 and 3 years to complete. According to NTSB, the number of 

safety studies it conducts is resource-driven. However, NTSB officials 

recognize the importance of these studies and would like to find ways to 

make them less resource intensive and more effective by decreasing the 

duration of these studies and the resources involved and finding ways to 

issue recommendations prior to completion of the studies. 

Table 4: Number of Safety Studies by Mode, Calendar Years 2000–2005 

Year Number of studies Mode

2000 1 Aviation(1)

2001 1 Aviation (1)

2002 0 Not applicable

2003 0 Not applicable

2004 0 Not applicable

2005 2 Aviation (1), pipeline (1) 

Source: GAO analysis of NTSB data. 

Another method by which NTSB accomplishes its transportation safety 

function is the use of public forums and symposia. Unlike public hearings, 

these deliberations are intended to gather information about safety issues 

affecting all modes of transportation, instead of one specific accident or 

mode. Public forums highlight safety issues that have been a factor in past

accident investigations and that will perhaps be an issue in the future 

should the transportation industry not take action. NTSB managers find 

that forums and symposia are not as resource intensive or as costly as 

public hearings because they do not require coordination of witnesses, 

parties, technical panels, and court reporters. 

Page 44 GAO-07-118 National Transportation Safety Board
While NTSB staff and other students at the training center have been 

positive about the quality of the courses, NTSB’s training center is not 

cost-effective, as the combination of the training center’s revenues and

external training costs avoided by NTSB staff’s use of the training center 

do not cover the training center’s costs. Training center revenues are 

affected by several factors, including low utilization of the training center 

and the availability of similar courses elsewhere that may reduce the 

number of students interested in training center classes. Furthermore, 

NTSB’s courses are already priced at or above market prices, making it 

unlikely that NTSB could raise its course prices, although decreasing 

course prices may attract more students and, thereby, increase total 

revenue. Potential strategies to increase revenues or decrease costs could 

increase the cost-effectiveness of the training center, although vacating the 

space may be the least-cost strategy, even if NTSB had to buy out the 

remaining lease. 

Assessing the financial impact of the training center on NTSB requires 

looking at both the revenues the training center generates and any costs 

that it enables NTSB to avoid, and comparing these revenues and avoided

costs with the direct costs of the training center. The training center 

generates revenues through tuition fees, subleasing space to other 

agencies for events such as conferences, and contracts with federal 

agencies that would allow them to use training center space for 

“continuity of operations” in emergency situations. 

NTSB’s Training 

Center Is Not CostEffective; Options 

Could Increase CostEffectiveness, but 

Vacating Space May 

Be Least-Cost 

Strategy 

Training Center’s Revenues

and Avoided Costs Do Not 

Cover Training Center’s

Costs 

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

training center did not generate sufficient revenues to cover the costs of 

providing training, as shown in table 5. As a result, those portions of the 

training center’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 training center, which 

would be appropriate to include in training center costs, are not included

in table 5. In addition, NTSB lacks a full cost-accounting system that 

would facilitate doing so. The table shows expenses directly associated 

with the training center and does not include an allocation of agencywide

supporting services, such as the Managing Director’s office, IT, 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 5 as office supplies and equipment for fiscal

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

Page 45 GAO-07-118 National Transportation Safety Board
airplane48 from storage near the crash site in New York to the training 

center (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 training 

center expenses, the remaining operating expenses exceeded revenues by

about $3.7 million in fiscal year 2004 and about $1.4 million the subsequent 

year. 

Table 5: Direct Expenses and Revenues for the NTSB Training Center, Fiscal Years 2004 and 2005 (unaudited) 

Fiscal year 2004 Fiscal year 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 and equipment $12,939 $153,249 1,084%

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

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

Earned revenuec$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: GAO analysis of information from NTSB. 

a

NTSB leases the training center from George Washington University under a 20-year lease that will 

expire in 2021. 

b

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

c

Earned revenue includes imputed fees for NTSB students. 

Other sources of revenue would be needed for NTSB to be able to recover 

the full costs of the training center. 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.49 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 

 48The wreckage is used for certain courses. 

49In fiscal year 2004, NTSB offered 11 gratis offerings to attract users and showcase the 

facilities. In fiscal year 2005, there were no gratis offers as the promotional aspect was no 

longer needed, according to NTSB. 

Page 46 GAO-07-118 National Transportation Safety Board
included subleasing 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. NTSB determines facility usage fees for 

subleasing space by assessing the square footage of each room, then using 

that square footage to determine what that figure represents in terms of 

the percentage of overall space. This percentage is then valued against the

lease for the facility, calculated on a per-day basis. Each room and lab 

space, therefore, carries a half day, full day, and weekly value that carries 

a charge reflecting its value, in terms of space, to the overall lease, but not 

in terms of the full cost of the space. In addition, NTSB has contracted 

with two agencies—the Federal Energy Regulatory Commission and the 

U.S. Veterans Affairs 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 use of the space. 

However, additional revenues from continuing the current practice of 

subleasing training center space is not likely to cover training center costs 

due to the magnitude of the training center’s deficit and because the fee 

structure does not cover the full cost of the space. Furthermore, NTSB 

does not have a business plan or marketing strategy that seeks to optimize 

opportunities for additional revenues. Previously, we recommended NTSB 

develop a comprehensive marketing plan that includes such things as 

outreach to potential users, marketing classroom and conference space,

and conducting market research for additional curriculum development.50

In response to our recommendation, NTSB has stated that it intends to 

formalize a marketing plan for the training center and make efforts to 

expand the current utilization of the space. 

Another element in the training center’s cost-effectiveness is the extent to

which the training center has allowed NTSB to avoid costs associated with 

external training. However, thus far, the training center has had a limited 

impact on external training costs—of about $1,041,000 annually—as the 

majority of students at the training center have been non-NTSB staff, and 

NTSB staff have taken a majority of their training courses through external 

sources. About 20 percent of the training center’s approximately 1,000 

students51 in fiscal year 2004 were NTSB staff, about 14 percent of the 

 50GAO-06-801T. 

51The total number of students is the sum of the participants in all classes. Individuals who 

attended more than one class at the training center were, therefore, counted multiple 

times. 

Page 47 GAO-07-118 National Transportation Safety Board
1,400 students in fiscal year 2005 were NTSB staff, and about 16 percent of

the 1,066 students in fiscal year 2006 were NTSB staff. During fiscal years 

2004 through 2006, about 570 NTSB students52 attended 55 of the 71 class 

sessions conducted at the training center. (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.53 However, in fiscal year 2006,

none of the 22 sessions was only for NTSB investigators. 

Figure 13: Number of NTSB and Non-NTSB Students, Fiscal Years 2004-2006 

0

200

400

600

800

1,000

1,200

1,400

2004 2005 2006

Number of students

Source: GAO analysis of NTSB data.

Fiscal year

NTSB students

Non-NTSB students

NTSB staff receive most of their training from outside the training center, 

which may be due to the training center 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 was expected to be from external 

 52Individuals that attend more than one class are counted multiple times. 

53These 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 48 GAO-07-118 National Transportation Safety Board
sources and the remaining training from NTSB’s training center. NTSB 

staff requested external training being provided by organizations that 

include FAA’s Transportation Safety Institute (TSI), the University of 

Southern California, the U.S. Department of Agriculture, and Kettering 

University on subjects such as human factors in aviation safety, turbine 

engine investigation, and automotive design and safety.54 Staff training 

requests also cover other specialties such as helicopter training, flight 

training currency for pilots, technical writing, supervisory and

management skills, and industry conferences. A majority of the 25 

investigators and writer-editors with whom we spoke had positive views 

on the quality of training center courses but provided several reasons for 

not taking further courses there. Ten of the 25 investigators and writereditors we interviewed told us that they had taken (or taught) courses at 

the training center and thought the courses were excellent;55 none of the 

investigators and writer-editors had anything negative to say about the 

quality of any training center course. In addition, our review of students’ 

course evaluations for fiscal years 2004 and 2005 indicated high positive 

responses. However, none of the NTSB staff we talked with had plans to 

attend training center courses 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-incharge. Eight investigators told us that they find workshops by 

manufacturers, such as aircraft and automobile manufacturers, more 

valuable to their work than courses held at the training center.

The training center 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 training center. The training center only offers one course 

that is required for NTSB’s aviation investigator staff—-a 2-week course on

aviation accident investigation. There are no refresher courses for aviation 

accident investigation. The Deputy Manager of the training center told us 

that the training center plans to eventually offer more internal training 

covering subjects such as management skills, retirement, and computers.56

However, no milestones or specific plans have been established for that 

 54Some subjects, such as human factors, are also taught at NTSB’s training center. 

55Our review of course evaluations for fiscal years 2004 and 2005 indicated high positive 

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

compare evaluations by NTSB students and non-NTSB students. 

56NTSB is considering contracting out more courses such as these. 

Page 49 GAO-07-118 National Transportation Safety Board
effort, and the cost of developing those courses has not been estimated. 

Moreover, even if NTSB were able to completely replace external training

with courses at the training center (an unlikely scenario), avoiding NTSB’s 

current external training costs of $1,041,000 annually would not come 

close to offsetting the training center’s annual lease costs of $2.5 million.

Training Center Revenues 

Are Affected by Low 

Utilization, Availability of 

Courses Elsewhere, and 

Courses at or Above 

Market Prices 

The training center’s revenues are affected by several factors, including 

low utilization, the availability of similar courses elsewhere, and the fact

that the courses are already at or above market prices. Although there is 

no statutory requirement that NTSB’s training center generate sufficient 

revenues to cover its 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.57

To the extent that NTSB maximizes the use of the training center, it can 

produce additional revenues that may help cover costs. However, NTSB 

has not maximized the use of its training center.58 We estimate that, 

overall, less than 10 percent of the available classroom capacity was used 

during fiscal years 2005 and 2006.59 Figure 14 shows the days in which 

classroom space was used for 22 class sessions and 22 other events, such

as workshops and seminars by organizations that subleased the space

during fiscal year 2006. As shown in the figure, classroom space was not 

used at all during October 2005 and March 2006 and during November, 

January, February, and August, classrooms were in use 4 days or less. In 

addition, at any given time, no more than three classrooms were in use at 

one time. 

 57Senate Report 109-109 accompanying Pub. L. No. 109-115, the Transportation, Treasury, 

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

of 2006. 

58The training center facility contains five classrooms (including an auditorium); a large

area that houses the TWA flight 800 reconstruction, aircraft, and other wreckage; eating

and lounge areas; and office space for six employees who constitute NTSB’s Mid-Atlantic 

Regional Aviation Office. 

59We excluded federal holidays and the last week in December from our analysis because 

we would not expect space to be used on those days. In some cases, courses used multiple

classrooms. We estimated one classroom was used per course because we lacked specific 

information on which courses used multiple classrooms. To account for that situation, we

rounded up the percentage of space utilized. 

Page 50 GAO-07-118 National Transportation Safety Board
Figure 14: Utilization of Training Center Classrooms by Classes and Other Events, Fiscal Year 2006 

1234

5 6 7 8 9 10 11

12 13 14 15 16 17 18

19 20 21 22 23 24 25

26 27 28

1234

5 6 7 8 9 10 11

12 13 14 15 16 17 18

19 20 21 22 23 24 25

26 27 28 29 30 31

31

1 2

3 4 5 6 789

10 11 12 13 14 15 16

17 18 19 20 21 22 23

24 25 26 27 28 29 30

1 234 56

7 8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23 24 25 26 27

28 29 30 31

Source: GAO analysis of NTSB information.

Classroom in use

Second classroom in use

Third classroom in use

1

2 3 4 5678

9 10 11 12 13 14 15

16 17 18 19 20 21 22

23 24 25 26 27 28 29

30 31

1

2 3 4 5 6 7 8

9 10 11 12 13 14 15

16 17 18 19 20 21 22

23 24 25 26 27 28 29

30 31

1

2 3 4 5 6 7 8

9 10 11 12 13 14 15

16 17 18 19 20 21 22

23 24 25 26 27 28 29

30

29 30

1 234 5

6 7 8 9 10 11 12

13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28

29 30 31

1 2 3 4 5

7 8 9 10 11 12

13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28

123

4 5678 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 27 28 29 30

123

4 5678 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 27 28 29 30

1 234 56 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31

October 2005 November 2005 December 2005 January 2006

February 2006 March 2006 April 2006 May 2006

June 2006 July 2006 August 2006 September 2006

Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa 

Su M Tu W Th F Sa Su M Tu W Th F Sa 

Su M Tu W Th F Sa Su M Tu W Th F Sa 

Su M Tu W Th F Sa 

Su M Tu W Th F Sa 

Su M Tu W Th F Sa 

Su M Tu W Th F Sa 

Note: Bars indicate courses or events. For example, two stacked bars indicate that two courses or

events took place on a particular day. 

The training center’s revenues are also affected by limitations associated 

with current course offerings and the fact that NTSB has not identified a 

Page 51 GAO-07-118 National Transportation Safety Board
market niche for its course offerings. Most students at the training center 

are from outside NTSB; however, several factors affect the agency’s ability 

to attract additional outside students. The training currently offered at the 

training center is similar to training provided by other institutions. FRA, 

FAA, and PHMSA officials told us that their inspectors do not attend NTSB 

training because similar training is provided in-house by DOT’s TSI. For 

example, an FAA inspector told us that new inspectors take a basic 

accident investigation course at TSI and subsequently take midcareer 

follow-up 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, TSI offers basic 

courses on aviation and bus accident investigations, and the University of 

Southern California offers a course on human factors related to accident 

investigations. Moreover, as mentioned previously, NTSB staff described 

choosing external training over NTSB courses because of more specialized 

offerings that are only offered elsewhere, such as workshops by aircraft 

manufacturers. 

NTSB is unlikely to be able to increase revenue by increasing course 

prices, as its courses are already offered at or above market prices. While 

NTSB charges tuition at a level to generally cover the class costs 

(excluding facility costs), charging higher tuition to include facility costs 

would put NTSB at a competitive disadvantage to other institutions that 

provide courses on accident investigations. Currently, NTSB determines 

tuition prices by estimating direct course costs (such as the costs for 

course materials, contracted instructors, and the instructors’ travel) and 

dividing that cost by the projected class size. As a result, for certain 

courses, the NTSB training center charges as much or more per course 

than the average cost per course charged by other safety institutions, and 

any additional charges for NTSB’s courses could reduce the training 

center’s revenues by pricing the courses out of comparable range for other 

transportation safety training institutions. For example, the cost of NTSB’s 

Aviation Accident Investigation course for the upcoming year is $2,950 for 

10 days of instruction. TSI’s 8-day course on aviation accident

investigation currently costs $1,844, and the Southern California Safety

Institute’s similar 11-day course costs $2,875. If enrollment is sensitive to 

the course price, NTSB may be able to increase revenue by lowering 

course prices to increase enrollment. However, NTSB would have to 

compare the change in revenue with the change in cost from the increased

enrollment. 

Page 52 GAO-07-118 National Transportation Safety Board
Furthermore, NTSB training center’s courses are also priced higher than 

comparable courses when measured by cost per student hour, even when 

the fixed annual expense of leasing the facility is not considered as part of

the cost.60 For example, NTSB’s cost per student hour of $55.71 is 

considerably higher than the $18.64 average cost per student hour of 

TSI’s,61 a fee-for-service organization that provides transit, aviation, 

pipeline, motor carrier, highway safety, hazardous material, and risk 

management training nationally and internationally. If the cost to lease 

training center space, a fixed annual expense of about $2.5 million, were 

divided among the students who now attend the training center, class 

costs would dramatically increase and would be even less competitive 

with fees charged by other institutions for similar courses unless the 

annual fixed cost was offset by revenue from a large influx of additional 

students. For example, if the training center lease cost of $2.5 million was 

divided among the 36,160 student hours in fiscal year 2005, the additional 

cost per student hour would be about $69 for a new total of almost $125 

per student hour. For NTSB’s 10-day Aircraft Accident Investigation 

course, the additional cost per student would be $5,530, increasing the 

cost to the student from $2,950 to nearly $8,500. 

Several Options Could 

Increase Revenues or 

Reduce Costs 

To determine a long-term strategy for the training center, options to 

increase revenues or to reduce costs need to be considered. Alternatively,

it could be determined that the center is not self-sufficient and subsidies 

are necessary. We have summarized various alternatives. 

The first option would involve attempting to increase training center 

revenues through attracting more external students. However, to cover the

$2.5 million annual cost of NTSB’s lease, the training center would have to 

add approximately 44,875 student hours above the approximately 36,000 

student hours in fiscal year 2005. Revenues gained in this manner would 

be offset by increased costs of additional classes and instructors; 

moreover, this option remains unlikely to attract additional DOT students 

as DOT agencies prefer to send students to its own institute (TSI). 

 60We calculated NTSB’s cost per student hour by dividing its operating costs for fiscal year 

2005 of $2,014,382 by its total number of fiscal year 2005 student hours—36,160—for a cost 

per student hour of $55.71. TSI has a budget of $10,840,000, and its 581,397 student training 

hours brings its cost per student hour to $18.64. We do not know how the NTSB and TSI 

courses compare in quality because such information is not available. 

61DOT’s TSI was established in 1971 to assist DOT modal administrations accomplish their 

mission essential training requirements. 

Page 53 GAO-07-118 National Transportation Safety Board
Officials from FRA, FAA, and PHMSA told us that their inspectors do not 

attend NTSB training because TSI provides similar training in-house. 

Moreover, to the extent that NTSB competes with other federal training 

entities, its training center is contrary to the governmentwide initiative to

consolidate and share services. However, if NTSB were to identify a 

market niche and offer different courses, it could potentially attract and 

retain new students and would not be out-of-step with the 

governmentwide initiative. To attract more external students to the 

training center, NTSB could create unique courses and aggressively 

market them. A marketing study could help NTSB assess the demand for 

different types of courses. Other actions NTSB could take include 

marketing courses through GSA and the U. S. Department of Agriculture’s 

Graduate School and listing the availability of training center courses on 

the GSA Web site,62 which allows GSA to identify training opportunities for 

personnel in the federal aviation community, such as “annual aviation

workshops” and “training for federal aviation.” Other training entities, 

including TSI, Embry-Riddle Aeronautical University, and the Southern 

California Safety Institute, publicize their aviation training on this site. 

Second, our analysis of the training center lease indicates that NTSB has 

the flexibility to use the facility in other ways to increase revenues. 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 training center is located in an academic setting on George 

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

market space to academic users. NTSB could also potentially sublease the

entire facility. However, subleasing may not help NTSB to recover training 

center costs.

In the past, NTSB has subleased portions of the facility and has retained 

resulting funds for their own uses. NTSB maintains that they have specific

authority to retain these funds rather than depositing them in the General 

Fund of the Treasury.63 NTSB has stated that when they sublease the 

training center facilities they, as a general principle, require for nonfederal

entities that the use or user has a relationship to transportation safety 

and/or accident investigation; however, NTSB does not require this of 

federal agencies. 

 62www.gsa.gov/aircraftpolicy. 

63The Miscellaneous Receipts statute, 31 U.S.C § 3302(b), would require the funds to be

deposited into the General Fund of the Treasury. 

Page 54 GAO-07-118 National Transportation Safety Board
NTSB has authority under its statue to “negotiate and enter into 

agreements...for the provision of facilities, accident-related and technical 

services or training in accident investigation theory and techniques....”64

NTSB reads the authority for the “provision of facilities” as allowing it to 

sublease space, since that authority is in a distinct, independent clause and 

is not restricted (as are services and training) to accident-related 

purposes. NTSB’s reading that the “provision of facilities” is not restricted 

to accident-related purposes is a reasonable interpretation given the 

structure of the statute and the absence of any contrary indication in the 

legislative history.65 Thus, NTSB has authority to enter into agreements for 

the provision of facilities and retain the resulting fees, including those 

resulting from subleasing the NTSB training facility.66

Third, NTSB could work to minimize the loss incurred by the training 

center by using the training center to reduce NTSB costs in other areas. 

NTSB has the ability to provide more courses that are geared to NTSB 

staff in order to replace some of the external courses they currently take,

perhaps at less cost. To attract more internal students, we have 

recommended that NTSB develop a core curriculum and add more classes 

that address the skills and competencies needed by its investigative staff. 

Other actions that NTSB could take to increase internal enrollment at the 

training center include allowing transportation manufacturers to conduct 

company-sponsored symposiums and technical training at the training 

center, which could help NTSB investigators keep up with new 

technologies and offering more internal training on subjects such as 

management skills, retirement, and computers. Attracting more internal 

students would not increase revenues for NTSB but would lower its 

external training costs. 

Fourth, NTSB is not precluded by its training center lease or its lease for 

headquarters space in Washington, D.C., from relocating some 

 6449 U.S.C. § 1113(b)(1)(I).

65While the legislative history of this provision demonstrates that it was amended during 

reauthorization to address NTSB’s authority to enter into agreements to provide accidentrelated training and services to foreign governments, there is nothing to elucidate the 

purposes for the provision of facilities.

66NTSB additionally asserts that 49 U.S.C. § 1118(c) grants them specific authority to retain

funds resulting from subleases. Because 49 U.S.C. § 1113(b)(1)(I) specifically provides for 

the provision of facilities, it is consequently determinative of NTSB’s authority in this 

instance rather than 49 U.S.C. §1118(c) where no such specific provision exists. Thus, it is

unnecessary to address the issue of whether a sublease is a “service” under § 1118(c)(2). 

Page 55 GAO-07-118 National Transportation Safety Board
headquarters staff to the Virginia facility. The lease for the office space in 

Washington, D.C., expires in October 2010. 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 that 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. Moreover, the desirability of working at this location 

would also have to be considered. Some staff told us they do not attend 

classes at the training center because of its undesirable location. 

At this time, there is very little difference in the base cost of the training 

center lease and the headquarters lease at L’Enfant Plaza. Specifically, the 

headquarters lease requires an additional expense of real estate taxes at 

about $3 per square foot since the lease is through a privately-owned 

business, while the training center is leased through a nonprofit 

organization, which is exempt from those taxes. Upon renewal in fiscal 

year 2011, the cost of the downtown lease could increase or decrease, but

that is unknown. Furthermore, the costs of relocation could equal or 

exceed the savings that NTSB might realize by moving some staff to the 

training center and renting less space in Washington, D.C. For example, 

the training center is currently configured as 4 classrooms and an 

auditorium so an immediate cost would be new construction to configure 

office space. Other costs could include computer and phone networks, 

relocating staff, moving furniture and laboratory and other equipment. We 

have recommended that NTSB conduct a study to determine the costs and 

feasibility of moving certain functions from headquarters to the training 

center.67

A fifth option to reduce costs would be to buy out the lease and vacate the 

space. Considering the severe budget environment and the projection that 

NTSB courses will most likely never cover training center costs, this may

be the least-cost strategy. NTSB does not have a cancellation clause in the

lease. Lack of a cancellation clause is not unusual because it allows for a 

lower monthly payment for the agency, but it also precludes NTSB from 

freeing up these funds for any other use during the life of the lease. Since 

there is no cancellation clause in the lease, NTSB may have to pay the

remainder of the 20-year lease should it vacate the facility, which could

amount to about $2.5 million annually through 2021 (a total cost of $42.5 

million). Some additional costs would be incurred to move training center 

 67GAO-06-801T. 

Page 56 GAO-07-118 National Transportation Safety Board
and regional office staff from the training center facility to NTSB’s 

headquarters office. This option would eliminate the possible yearly cost 

of several million dollars (the current deficit) and allow the money to be

used for other purposes. For example, if the funds currently going to the 

training center were used for NTSB’s investigations and investigative staff, 

they would more directly support NTSB’s mission. We estimate that the 

net expenses of the training center, including the cost of the lease, totaling 

$3,880,478 in fiscal year 2005 could fund over 25 additional investigative 

positions each year. 

NTSB’s progress in following some leading management practices, such as

correcting some computer security vulnerabilities, developing a detailed 

staffing plan, and improving communications from senior management to

staff, are positive steps in ensuring that the agency’s management is 

designed to support its mission. In addition, NTSB’s steps toward 

responding to our recent recommendations regarding leading management 

practices in areas such as strategic planning and communication are 

further positive steps. However, key gaps in NTSB’s management practices

remain. The continued lack of comprehensive plans and policies in the 

areas of IT, knowledge management, strategic human capital management, 

and certain acquisition practices suggest that NTSB is still not ensuring 

that its management of these areas is aligned to fully and effectively

support its mission. 

Conclusions 

Since NTSB lacks the resources to investigate all accidents, ensuring that 

it performs investigative activities with the greatest transportation safety 

payoff is also critical to its ability to effectively support its mission. While 

NTSB’s investigative activities contain many strong elements, we 

identified some limitations that make it difficult for NTSB to ensure it is 

using its resources as wisely as possible. Specifically, NTSB’s lack of riskbased criteria for investigations in some modes reduces its assurance it is 

using its resources effectively. Furthermore, when criteria exist, they are 

sometimes included in an interoffice memorandum, rather than in a 

transparent policy document, such as a board order. In addition, NTSB’s 

limited use of safety studies (only four in the past 6 years) to proactively 

examine and highlight safety issues may limit the effectiveness of its work 

on behalf of improving overall transportation safety. 

Finally, NTSB is facing several challenges related to the costs of its 

training center. First, although NTSB has identified the fact that it is in 

violation of the Anti-Deficiency Act because it is making lease payments 

for the training center annually when it should have been funded from its 

Page 57 GAO-07-118 National Transportation Safety Board
budget authority in fiscal year 2001, it does not have the resources to 

correct this deficiency. Second, NTSB is missing opportunities to make the 

training center cost-effective. Without a comprehensive business plan, 

NTSB will likely be unable to efficiently attract users who would help pay 

the ongoing costs of the facility. However, in the final analysis, NTSB may 

have difficulty increasing revenues or decreasing external training costs 

enough to ever fully offset the training center’s costs. It is, therefore, 

important to consider the option of buying out the lease and vacating the 

center entirely when considering how best to proceed. 

To improve the efficiency of agency operations, we recommend that the

Chairman of the National Transportation Safety Board take the following 

five actions: 

Recommendations for 

Executive Action 

• To improve agency performance in the key management areas of IT, 

knowledge management, and human capital management, NTSB should 

develop plans or policies for IT and knowledge management and develop a 

strategic human capital plan that is linked to its overall strategic plan. The 

human capital plan should include strategies on staffing, training, diversity 

management, and recruitment and retention. The IT plan should include a 

strategy to guide IT acquisitions. 

• To make the most effective use of its investigation resources and increase

transparency, NTSB should develop orders for all transportation modes 

that articulate risk-based criteria for determining which accidents would 

provide the greatest safety benefit to investigate or, in the case of aviation 

accidents, explain which accidents are investigated at the scene, or 

remotely, in a limited manner. 

• To be more proactive in identifying and correcting safety problems before 

accidents occur, NTSB should increase its utilization of safety studies. 

• NTSB should develop a business plan to increase the utilization of its 

training center or vacate it and submit the plan to Congress. As part of this 

effort, NTSB should determine the costs and feasibility of alternative 

actions such as adding more courses for NTSB staff, moving headquarters 

staff to the center, subleasing space to other entities, or buying out the 

lease. 

• NTSB should identify and implement actions to correct its violation of the 

Anti-Deficiency Act and bring the agency in compliance with the act.

These actions could include obtaining a deficiency appropriation for the 

full costs of the lease, renegotiating or terminating the training center 

Page 58 GAO-07-118 National Transportation Safety Board
lease so that it complies with the Anti-Deficiency Act, or obtaining 

authority to obligate lease payments using annual funds over the term of 

the lease. 

We provided a draft of this report to NTSB for their review and comment. 

The agency provided written comments (see app. IV). NTSB agreed with 

our recommendations and provided technical clarifications, which we 

incorporated into this report. 

As agreed with your offices, unless you publicly announce the contents of

this report earlier, we plan no further distribution until 8 days from the 

report date. At that time, we will send copies of this report to the 

Chairman of the National Transportation Safety Board and interested 

congressional committees. We also will make copies available to others 

upon request. In addition, the report will be available at no charge on the 

GAO Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact me 

at (202) 512-2834 or dillinghamg@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made major contributions to this report 

are listed in appendix V.

Gerald L. Dillingham, Ph.D. 

Director, Physical Infrastructure Issues 

Agency Comments 

Page 59 GAO-07-118 National Transportation Safety Board
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

To determine the extent to which the National Transportation Safety 

Board (NTSB) is following leading practices in selected management 

areas, we reviewed past GAO work on leading management practices in 

the areas of strategic planning, human capital management, 

communications, acquisition management, financial accountability and 

control, information technology, and knowledge management. We did not 

evaluate NTSB’s performance in the area of capital decision making 

because the agency does not have a large amount of either capital assets 

or capital acquisitions. With assistance from GAO specialists in the 

functional areas, we assessed whether NTSB was mostly following the 

practices (plans or policies for all or nearly all practices have been 

developed and implemented properly), partially following them (plans or 

policies are in place and implemented properly for some practices), or 

minimally following them (plans or policies are lacking for all or nearly all 

practices). We reviewed the results of the Office of Personnel 

Management’s (OPM) 2004 Federal Human Capital Survey for NTSB in the 

areas of recruitment, staff development and retention, training, 

communications, and knowledge management. OPM conducted the survey 

during the fall 2004. The survey included 88 items that measured federal

employee perceptions about how effectively agencies are managing their 

workforces. For more information about the 2004 survey, see 

http://www.fhcs2004.opm.gov/. On the basis of our examination of the 

OPM data and review of prior GAO work concerning survey design, 

administration, and processing, we determined that the data were 

sufficiently reliable for the purpose of our review. 

We reviewed recommendations made by the RAND Corporation1

 and Booz 

Allen Hamilton2

and NTSB’s responses to those recommendations. Both 

studies set forth recommendations aimed at strengthening NTSB’s ability 

to carry out its safety mission. We interviewed current and former NSTB 

board members, senior officials, and division managers and selected

investigators and writer-editors regarding their experience with those 

practices at NTSB and their perceptions of the effectiveness of those 

practices. We randomly selected 17 of the 203 investigators and 8 writereditors roughly evenly across NTSB’s four modal offices. The views of 

these particular individuals are not representative of all NTSB

 1

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

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

2

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

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

Page 60 GAO-07-118 National Transportation Safety Board
Appendix I: Scope and Methodology 

investigators and writer-editors. We also determined NTSB’s response to 

recommendations made by the Department of Transportation’s Inspector 

General. We reviewed NTSB documents, including strategic, staffing, and

performance management plans; management advisory e-mails; 

information regarding the current staffing levels; and employees’ training 

plans for 2006. 

To determine the extent to which NTSB accomplishes its accident 

investigation function, develops accident investigation reports, and closes

safety recommendations in an efficient manner, we reviewed policy 

guidance, including orders, investigative manuals and data on the level of 

current and past investigation activity. Additionally, we reviewed studies 

by the RAND Corporation and Booz Allen Hamilton that examined NTSB’s 

investigation process and determined the extent to which the agency had 

implemented their recommendations. We interviewed NTSB managers and 

staff mentioned previously, as well as industry and government 

stakeholders, including federal agencies that receive NTSB 

recommendations; aviation, rail, marine, and highway associations; and 

transportation safety advocacy groups (see table 6). We examined data on 

recommendations acceptance rates and closeout status from NTSB’s 

recommendation database, and we determined that the data were 

sufficiently reliable for the objectives of this review. 

Table 6: Entities Interviewed by GAO

Type Name of entity

Federal agency Federal Aviation Administration

Federal Motor Carrier Safety Administration

Federal Railroad Administration 

National Highway Traffic Safety Administration 

Pipeline and Hazardous Materials Safety Administration

U.S. Coast Guard 

Industry or safety organization AFL-CIO

Airline Pilots Association 

Air Transport Association 

American Association of Railroads 

Association of Flight Attendants 

Brotherhood of Locomotive Engineers and Trainmen

Brotherhood of Railroad Signalmen 

Commercial Vehicle Safety Alliance 

International Organization of Masters, Mates, and Pilots

Page 61 GAO-07-118 National Transportation Safety Board
Appendix I: Scope and Methodology 

Type Name of entity

Maritime Institute for Research and Industrial

Development 

Operation Lifesaver

Regional Airline Association 

Transit Workers Union of America AFL-CIO

Transportation Communications International Union 

United Transportation Union 

Source: GAO.

To analyze safety recommendations issued recently by NTSB, we analyzed

a data extract from NTSB’s safety recommendations database for 

recommendations issued from October 1, 1995, and forward. A list of the

data fields we requested is located in table 7. From the data NTSB 

provided, we determined the number of safety recommendations issued by 

year and by mode of transportation, as well as the number of accident 

investigations that yielded these recommendations. We determined the 

percentages of recommendations by mode that are open and closed, and 

also the “acceptance” rate by mode of closed recommendations only. 

Table 7: Safety Recommendation Data Fields Analyzed

Field Definition

Mode Mode of transportation, such as aviation, highway, marine, 

pipeline, or rail

Recommendation number Number assigned by NTSB to distinguish safety 

recommendations 

Status Status of the recommendation, such as open or closed and 

whether the addressee for the recommendation is taking

acceptable or unacceptable action towards its 

implementation

Accident date Date of the accident associated with the safety

recommendation 

Date issued Date the safety recommendation was issued by NTSB to 

addressee(s) 

Date closed Date NTSB closed the recommendation 

Addressee Agency or organization that received the safety 

recommendation from NTSB 

Addressee status Status of a specific addressee’s response to NTSB’s 

recommendation 

Source: NTSB. 

Page 62 GAO-07-118 National Transportation Safety Board
Appendix I: Scope and Methodology 

To determine the extent to which NTSB’s training center is a cost-effective

investment and how it could be more cost-effective, we reviewed financial 

data on NTSB’s training center, including the revenues and expenses for 

fiscal years 2004 and 2005. We reviewed the course curriculum of the 

training center and compared it with classes offered by the Department of 

Transportation’s (DOT) Transportation Safety Institute, Embry-Riddle 

Aeronautical University, the University of Southern California, and the 

Southern California Safety Institute. We examined data on the student 

makeup of training center classes and analyzed data on the preparatory 

and teaching time used by NTSB investigators who taught at the training 

center. We interviewed NTSB investigators, writer-editors, and managers 

and senior officials at DOT’s modal administrations regarding their current 

and planned use of the training center. We also examined the subleasing of 

NTSB’s space for fiscal years 2004 through 2006, and examined the lease 

for the training center to determine how NTSB may utilize the space. 

Finally, we examined the Anti-Deficiency Act violation related to the lease 

agreement for the NTSB training center and reviewed legislation for 

corrective action. 

We conducted our review from December 2005 to November 2006 in

accordance with generally accepted government auditing standards. 

Page 63 GAO-07-118 National Transportation Safety Board
Appendix II: Prior GAO Recommendations to Appendix II: Prior GAO Recommendations to NTSB 

NTSB 

Based on our ongoing work as of May 2006, to improve the efficiency of 

agency operations we recommended the Chairman of the National 

Transportation Safety Board take the following eight actions:1

• 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 

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.

• 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. 

• Develop a comprehensive marketing plan for the training center. The plan

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

the U. S. Department of Agriculture’s Graduate School and the General 

Services Administration 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 

facility, which would benefit NTSB investigators in keeping up with new 

 1

GAO-06-801T. 

Page 64 GAO-07-118 National Transportation Safety Board
Appendix II: Prior GAO Recommendations to

NTSB 

technologies. In addition, the plan should consider the feasibility of 

subleasing a portion of the training center’s space. 

• Develop core investigator curriculum for each mode and maximize the 

delivery of that training at the training center. 

• Conduct a study to determine the costs and feasibility of moving certain 

functions from headquarters to the training center in preparation for the

renegotiation of the headquarters lease, which expires in fiscal year 2011. 

Page 65 GAO-07-118 National Transportation Safety Board
Appendix III: Additiona

Safety Reco

l Analysis of NTSB 

mmendations Data

Page 66 GAO-07-118

Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data 

Figure 15: Number of Recommendations by Mode of Transportation and by Year Issued, Calendar Years 1996-2006 

Number of recommendations

Year

Railroad

Pipeline

Marine

Highway

Aviation

Source: GAO analysis of NTSB data.

0

100

200

300

400

500

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Note: NTSB issued a total of 2,417 safety recommendations from January 1, 1996, through June 8, 

2006. Calendar year 2006 includes data through June 8, 2006. 

National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

Figure 16: Number of Accident Investigations with Safety Recommendations, 

Calendar Years 1996-2006 

0

50

100

150

200

250

Aviation Highway Marine Pipeline Railroad

Number of investigations

Source: GAO analysis of NTSB data.

Mode

Note: A total of 443 accident investigations resulted in safety recommendations. Calendar year 2006 

includes data through June 8, 2006. 

Page 67 GAO-07-118 National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

Figure 17: Number of Investigations Completed by Mode, Calendar Years 1996-2006

Number of investigations

Year

Railroad

Pipeline

Marine

Highway

Aviation

Source: GAO analysis of NTSB data.

0

10

20

30

40

50

60

70

80

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Note: A total of 443 investigations that resulted in safety recommendations were completed from 

January 1, 1996, through June 8, 2006. Calendar year 2006 includes data through June 8, 2006. 

Page 68 GAO-07-118 National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

[This page left intentionally blank] 

Page 69 GAO-07-118 National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

Figure 18: Average Investigation Duration by Mode, Calendar Years 1996-2006 

0

200

400

600

800

1,000

1,200

1996 1997 1998 1999

Number of days

Year

Page 70 GAO-07-118 National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

2000 2001 2002

Source: GAO analysis of NTSB data.

Railroad

Pipeline

Marine

Highway

Aviation

2003 2004 2005 2006

Note: A total of 443 investigations that resulted in safety recommendations were completed from 

January 1, 1996, through June 8, 2006. There were no pipeline investigations completed from 

January 1, 2005, through June 8, 2006, that resulted in safety recommendations. Calendar year 2006

includes data through June 8, 2006. 

Page 71 GAO-07-118 National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

Table 8: Number and Percentage of NTSB Safety Recommendations with Closed Acceptable, Closed Unacceptable, and Open

Status by Mode, for Recommendations Issued Calendar Years 1996-2005 

Year issued

Mode Status 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Aviation Closed acceptable 140

(78%) 

105

(83%)

91

(68%)

60

(70%)

90

(63%)

50

(61%)

21 

(53%) 

22

(29%)

6

(8%)

2

(6%)

Closed unacceptable 28

(16%) 

15

(12%)

24

(18%)

9

(10%)

13

(9%)

0

(0%)

1 

(3%) 

0

(0%)

2

(3%)

0

(0%)

Open 11

(6%) 

6

(5%)

19

(14%)

17

(20%)

41

(28%)

32

(39%)

18

(45%) 

54

(71%)

66

(89%)

33

(94%)

Total 179

100% 

126

100%

134

100%

86

100%

144

100%

82

100%

40 

100% 

76

100%

74

100%

35

100%

Highway Closed acceptable 39 

(66%) 

30

(77%)

33

(67%)

39

(55%)

14

(42%)

11

(30%)

15 

(33%) 

8

(25%)

11

(23%)

2

(6%)

Closed unacceptable 6

(10%) 

1

(3%)

5

(10%)

6

(8%)

0

(0%)

0

(0%)

0 

(0%) 

0

(0%)

0

(0%)

0

(0%)

Open 14

(24%) 

8

(21%)

11

(22%)

26

(37%)

19

(58%)

26

(70%)

30 

(67%) 

24

(75%)

37

(77%)

30

(94%)

Total 59

100% 

39

101%

49

99%

71

100%

33

100%

37

100%

45 

100% 

32

100%

48

100%

32

100%

Marine Closed acceptable 14

(74%) 

54

(86%)

83

(66%)

20

(91%)

26

(72%)

18

(78%)

16 

(52%) 

0

(0%)

1

(25%)

2

(13%)

Closed unacceptable 5

(26%) 

7

(11%)

32

(25%)

0

(0%)

1

(3%)

0

(0%)

2 

(6%) 

0

(0%)

0

(0%)

0

(0%)

Open 0

(0%) 

2

(3%)

11

(9%)

2

(9%)

9

(25%)

5

(22%)

13

(42%) 

1

(100%)

3

(75%)

13

(87%)

Total 19

100% 

64

100%

126

100%

22

100%

36

100%

23

100%

31 

100% 

1

100%

4

100%

15

100%

Pipeline Closed acceptable 22

(76%) 

5

(100%)

61

(82%)

8

(67%)

21

(81%)

3

(75%)

3

(60%) 

2

(50%)

6

(43%)

0

(0%)

Closed unacceptable 7

(24%) 

0

(0%)

11

(15%)

2

(17%)

3

(12%)

0

(0%)

0 

(0%) 

0

(0%)

0

(0%)

0

(0%)

Open 0

(0%) 

0

(0%)

2

(3%)

2

(17%)

2

(8%)

1

(25%)

2 

(40%) 

2

(50%)

8

(57%)

5

(100%)

Total 29

100% 

5

100%

74

100%

12

101%

26

101%

4

100%

5 

100% 

4

100%

14

100%

5

100%

Railroad Closed acceptable 64

(97%) 

59

(87%)

63

(93%)

61

(100%)

11

(65%)

18

(72%)

14 

(45%) 

9

(39%)

1

(8%)

2

(9%)

Page 72 GAO-07-118 National Transportation Safety Board
Appendix III: Additional Analysis of NTSB 

Safety Recommendations Data

Year issued

Mode Status 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Closed unacceptable 2

(3%) 

3

(4%)

4

(6%)

0

(0%)

0

(0%)

0

(0%)

0 

(0%) 

1

(4%)

0

(0%)

0

(0%)

Open 0

(0%) 

6

(9%)

1

(1%)

0

(0%)

6

(35%)

7

(28%)

17 

(55%) 

13

(57%)

11

(92%)

20

(91%)

Total 66

100% 

68

100%

69

100%

61

100%

17

100%

25

100%

31 

100% 

23

100%

12

100%

22

100%

Source: GAO analysis of NTSB data. 

Note: A total of 2,333 recommendations were issued from 1996 through 2005. Percentages do not 

always total to 100 due to rounding. 

Figure 19: Percentage of Safety Recommendations Open for at Least 5 Years, by

Mode

0

5

10

15

20

25

30

35

Aviation Highway Marine Pipeline Railroad Total

Percentage of recommendations

Source: GAO analysis of NTSB data.

Mode

Note: Recommendations were issued calendar years 1995-2001. 

Page 73 GAO-07-118 National Transportation Safety Board
Appendix IV: Comments from the National Transportation Safety Board Appendix IV: Comments from the National 

Transportation Safety Board 

Page 74 GAO-07-118 National Transportation Safety Board
Appendix IV: Comments from the National Transportation Safety Board 

Page 75 GAO-07-118 National Transportation Safety Board
Appendix V: GAO Contact and Staff Acknowledgments

Page 76 GAO-07-118

Appendix V: GAO Contact and Staff 

Acknowledgments 

Gerald L. Dillingham, Ph.D., (202) 512-2834, or dillinghamg@gao.gov

In addition to the contact named above, Teresa Spisak, Assistant Director; 

Maren McAvoy; Lauren Calhoun; Eric Fielding; Colin Fallon; Dave Hooper; 

Tom Keightley; Ayeke Messam; Josh Ormond; Jena Whitley; and Alwynne 

Wilbur made significant contributions to this report. 

GAO Contact 

Staff 

Acknowledgments 

National Transportation Safety Board
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Page 77 GAO-07-118

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(540130) Page 78 GAO-07-118 National Transportation Safety Board
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