United States Government Accountability Office

Washington, DC 20548 

 

August 22, 2008 

Congressional Committees 

Subject: Chemical Safety Board: Improvements in Management and 

Oversight Are Needed

The principal role of the Chemical Safety and Hazard Investigation Board 

(CSB) is to investigate accidental releases of regulated or extremely 

hazardous substances to determine the conditions and circumstances that 

led to the accident and to identify the cause or causes so that similar 

accidents might be prevented.1

 Accidental releases of these toxic and 

hazardous chemicals occur frequently and often have serious

consequences. CSB reported to Congress that the agency received 

notification of approximately 900 chemical accidents in calendar year 

2007, and that 31 of these accidents were serious or even fatal events that

warranted the commitment of CSB investigators.

CSB began operating in 1998 as an independent agency created under the 

Clean Air Act Amendments of 1990. The act directs CSB to (1) investigate 

and report on the cause or probable cause of any accidental chemical 

releases from stationary sources resulting in a fatality, serious injury, or 

substantial property damages; (2) make recommendations to reduce the 

likelihood or consequences of accidental chemical releases and propose 

corrective measures; and (3) establish regulations for reporting accidental 

releases. The agency publishes investigative reports and issues safety 

studies and videos to help prevent future accidents. Congress modeled 

CSB after the National Transportation Safety Board (NTSB), which has a 

similar public safety mission.2

 Like NTSB, CSB has no enforcement 

authority and a limited regulatory role. As outlined in the authorizing 

statute, CSB is to be managed by a five-member board. Currently the 

board has one vacancy. CSB received an appropriation of $9.4 million for 

fiscal year 2008 and had 39 staff as of January 30, 2008. 

 1

S. Rpt. No. 101-228, 1990 U.S.C.C.A.N. 3385, 3615 (1989). 

2

NTSB is required by statute to investigate every civil aviation accident in the United States 

and certain railroad, pipeline, and marine accidents and issue safety recommendations 

aimed at preventing future accidents. 

Page 1 GAO-08-864R Chemical Safety Board 
In 2000, Congress asked GAO to review CSB’s effectiveness in carrying out 

its mission. In our report, Chemical Safety Board: Improved Policies and 

Additional Oversight Are Needed (GAO/RCED-00-192),3

 we cited problems 

with CSB’s governance, management, policies, and procedures. Among 

other things, we recommended that CSB obtain the services of an existing 

office of inspector general (IG). Since fiscal year 2001, three IGs—from the 

Federal Emergency Management Agency (FEMA), the Department of 

Homeland Security (DHS), and the Environmental Protection Agency

(EPA)––have provided oversight to CSB. EPA’s IG currently provides 

oversight. Together, over time, these IGs have made 32 recommendations 

to address problems in management accountability and control, human 

capital management, compliance with its statutory requirements, and 

other issues. 

In response to a mandate in the Joint Explanatory Statement that 

accompanied the fiscal year 2008 Consolidated Appropriations Act,4

 we 

examined (1) how CSB has responded to GAO and IG recommendations 

regarding CSB’s investigative gap, data quality problems, human capital 

problems, and accountability and management problems for meeting its 

mission requirements and (2) the merits of the current oversight approach 

using an existing office of inspector general and other alternative 

approaches to oversight. On April 17, 2008, we briefed staff from the 

House and Senate Appropriation Subcommittees on Interior, Environment, 

and Related Agencies and on May 20, 2008, we briefed the Chairman of the 

House subcommittee. This letter summarizes the main points from our 

presentation. See enclosure II for a copy of the briefing slides from that 

presentation. 

To perform our review, we reviewed relevant documentation and data and 

interviewed CSB and other agency officials. We conducted this

performance audit from October 2007 to May 2008 in accordance with 

generally accepted government auditing standards. Those standards 

require that we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and conclusions based on our 

 3

GAO, Chemical Safety Board: Improved Policies and Additional Oversight Are Needed, 

GAO/RCED-00-192 (Washington, D.C.: July 11, 2000). 

4

Joint Explanatory Statement to Accompany the Consolidated Appropriations Amendment,

Division F, at 60. 

Page 2 GAO-08-864R Chemical Safety Board 
audit objectives. We determined that the agency’s accident-screening 

database is sufficiently reliable for the purpose of making broad estimates 

of the total number of accidents and accidents with fatalities. Among the 

data’s limitations is the lack of quality controls to ensure that data are 

accurate and complete, especially with respect to fatalities. For additional 

information on our scope and methodology, see enclosure I.

• CSB has implemented some GAO and IG recommendations related to 

improving its operating policies and procedures since we last reported in

July 2000. However, we found that CSB has not fully addressed several 

critical recommendations, and problems in governance, management, and

oversight persist. Specifically, CSB has not fully responded to key 

recommendations related to investigating more accidents that meet 

statutory requirements triggering CSB’s responsibility to investigate, 

improving the quality of its accident data, resolving human capital 

problems, and ensuring accountability and continuity of management. 

Summary of 

Findings 

• In our view, independent oversight from an existing IG remains the most 

effective way to help CSB address its continuing problems, provided that 

the arrangement is made permanent and funding is provided to the IG for 

the function.

We are making recommendations to the Chairman of CSB to address 

continuing problems with governance and management. We are also 

proposing matters for congressional consideration to address continuing 

problems with oversight. Regarding the six recommendations, CSB 

generally concurred with four and disagreed with two. CSB also disagreed 

with both matters for congressional consideration. CSB did not generally

concur with our recommendation to develop a plan to address the 

investigative gap and request the necessary resources from Congress to 

meet its statutory mandate but stated that it would work with Congress to 

clarify the issue of its statutory mandate and, if appropriate, seek an 

amendment to CSB’s authorizing statute. We believe that CSB’s willingness 

to work with Congress to clarify the issue of its statutory mandate, and if

appropriate, seek an amendment to CSB’s authorizing statute is a step in

the right direction. However, CSB does not agree that it must currently 

investigate all chemical accidents that meet statutory requirements 

triggering CSB’s responsibility to investigate. In this regard, CSB said it has 

“not construed the agency’s authorizing statute as requiring investigation 

of every chemical accident involving a fatality, serious injury, or 

substantial property damage, or the potential for such consequences.” We

continue to believe the current law is clear; investigations are required for 

all accidental releases that result, or have the potential to result, in a 

Page 3 GAO-08-864R Chemical Safety Board 
fatality, serious injury, or substantial property damage. CSB is currently 

investigating far fewer accidents than is required by law and a plan to 

address the investigative gap is still necessary. 

CSB also disagreed with our recommendation to publish a regulation to 

require facilities to report information on chemical accidents. We are 

encouraged that CSB plans to publish in the Federal Register a Request for 

Information (RFI) concerning a reporting regulation to obtain the views 

and opinions of CSB’s stakeholders. We recognize that this step could 

provide valuable information regarding the preparation of a reporting 

regulation. However, the request for information does not in itself provide 

assurance that CSB will follow through and issue a regulation as required 

by CSB’s authorizing statute. In this regard, CSB said that “a reporting 

regulation is not needed for the narrow purpose of notifying the CSB of 

major accidents warranting the deployment of investigators, which 

appears to be the sole purpose of CSB’s authority to issue a reporting 

rule.” We disagree with CSB’s view that a reporting regulation is not 

needed. CSB is legally required to promulgate a regulation. Furthermore, 

such a regulation would allow CSB to obtain more accurate, complete 

information to meet its statutory mandate. 

In addition, CSB disagreed with our matter for congressional 

consideration to consider amending CSB’s authorizing statute or the 

Inspector General (IG) Act of 1978 to permanently give EPA’s Inspector 

General the authority to serve as the oversight body for the agency. CSB 

questioned the independence of the EPA IG, since CSB issues 

recommendations to EPA. We understand CSB’s concerns; however, the 

IG Act requires inspectors general to be independent from the agencies 

they audit and investigate, and using the EPA IG does not pose a risk to 

CSB’s independent evaluation of chemical accidents.5

 Finally, CSB 

disagreed with our matter for congressional consideration to provide the 

EPA IG with appropriations and staff allocations specifically for the audit

of CSB via a direct line in the EPA appropriation. CSB said GAO did not 

adequately consider different oversight options for CSB and that oversight 

should be tailored to the size of the agency. We believe that all significant 

federal programs and entities should be subject to oversight by IGs who 

can provide sound independent audits of all significant federal operations 

and activities. The EPA IG has expertise involving the chemical

management issues that the Board is charged with investigating, has 

 5

Pub. L. No. 95-452, 92 Stat. 1101 (codified as amended at 5 U.S.C. App. 3). 

Page 4 GAO-08-864R Chemical Safety Board 
gained knowledge of CSB’s operations and activities in providing the 

Board with oversight over the past several years, and, like other IGs, has 

the requisite independence provided by the IG Act of 1978 necessary for 

reviewing and making recommendations to address long-standing 

problems in the Board’s management performance. Given the management 

problems that our audit revealed, the need for independent IG oversight at 

CSB is especially pressing. 

CSB has not fully responded to recommendations related to its 

investigative gap, data quality, human capital, and management problems, 

and we found these problems continue. 

CSB has not fully responded to recommendations to address its 

investigative gap—the difference between the number of accidents it 

investigates and the accidents that meet statutory criteria triggering CSB’s 

responsibility to investigate—and this gap persists. Using fiscal year 2002 

data, the DHS IG reported in fiscal year 2004 that CSB deployed to 4 of 294 

accidents that met statutory criteria for investigation. Moreover, while 

acknowledging that CSB lacked the resources to investigate all 294 

accidents, the IG reported that CSB did not have a plan for reporting to 

Congress on the number and type of accidents it was not able to 

investigate, nor did it have a plan for narrowing the investigative gap. 

Consequently, the IG recommended that CSB develop a plan to describe 

and address the investigative gap and include the information in future 

budget submissions to Congress and the Office of Management and Budget 

(OMB). In response, CSB prepared a onetime report to Congress in 2006. 

CSB officials told us they did not repeat this report because congressional 

staff did not request subsequent annual reports with this level of detail. 

Rather, it included less detailed information in subsequent budget 

justifications to Congress. 

In fiscal year 2007, we found that CSB received notifications of 920 

chemical accidents; approximately 35 of these accidents included at least 

one fatality, and CSB investigated 1 of these. By not investigating all 

accidental releases that have a fatality, serious injury, substantial property 

damage, or the potential for a fatality, serious injury, or substantial 

property damage, CSB continues to fall short of its statutory mandate. CSB 

officials said the agency lacks the resources to investigate more than a 

CSB Has Not Fully 

Addressed Key 

Recommendations, 

and Problems Persist 

The Investigative Gap 

Persists 

Page 5 GAO-08-864R Chemical Safety Board 
small percentage of the accidents that meet statutory criteria triggering the

board’s responsibility to investigate. Moreover, CSB has not developed a 

long-term plan for reporting to Congress on the scope and magnitude of its 

investigative gap or a detailed strategy to address it. As a result, Congress 

does not have accurate or comprehensive information about CSB’s 

investigative gap or the resources it would need to close it. 

When we compared CSB and NTSB data from 2006, we found that while 

NTSB’s budget is approximately 8 times CSB’s budget, NTSB investigates 

250 times as many accidents. Unlike CSB, NTSB conducts limited, officebased investigations that rely on the work of other entities. NTSB uses its 

statutory authority to solicit other entities’ work when resources, or other

considerations, prevent it from deploying investigators to the accident site, 

a fact that may help it better leverage its resources. For example, NTSB 

uses the work of local officials, rescue response units, Federal Aviation 

Administration (FAA) personnel, and other persons and organizations that 

might have knowledge of the accident. While CSB has similar statutory 

authority to use information gathered by others, the agency terminated its 

limited, office-based review program that relied on other entities work in 

1999. Although the limited review program was less resource intensive 

than full investigations, CSB officials said that they terminated the limited

reviews because relying on the work of other agencies conflicted with 

CSB’s independence. In 2006, we reported that NTSB’s use of others’ work 

may present some challenges, but appears to be working well.6

 Moreover, 

CSB has memorandums of understanding with both Occupational Safety

and Health Administration (OSHA) and EPA that state that CSB may use 

information gathered by OSHA and EPA to aid in its investigation of 

accidents. 

CSB has not fully responded to IG recommendations to publish a datareporting regulation and improve the quality of its accident data. As a 

result, data quality problems continue. In 2004, the DHS IG recommended 

that CSB fulfill its statutory requirement to publish a regulation for 

receiving information from facilities on their chemical accidents, and that

CSB develop a long-term strategy to improve the quality of its data. Since 

that time, CSB has not issued the regulation, and officials said they have 

Data Quality Problems 

Continue 

 6

GAO, National Transportation Safety Board: Progress Made, Management Practices,

Investigation Priorities, and Training Center Use Should Be Improved, GAO-07-118

(Washington, D.C.: Nov., 22, 2006). 

Page 6 GAO-08-864R Chemical Safety Board 
no plans to do so; instead CSB relies primarily on the media, such as 

online newspapers and television, to learn about chemical accidents. In 

addition, the DHS IG reported that CSB did not have adequate controls 

over the quality of data in the accident-screening database it uses to report 

to Congress and the public on the number of chemical accidents the 

agency screens and selects for investigation. The IG reported that CSB 

needed to monitor its data for completeness, accuracy, timeliness, and 

usefulness. 

We found that CSB lacks a long-term strategy to improve quality controls, 

and the data remain somewhat inaccurate and incomplete. For example, 

when we analyzed a subset of accidents in the database involving fatalities 

and injuries, we found at least five accidents (about 6 percent of the cases 

reviewed) where fatalities were not correctly recorded in the database. We

also found seven accidents (about 4 percent of the cases reviewed) where 

data on injuries were missing as a result of incomplete data entry. 

Moreover, CSB does not have procedures to ensure that data has been 

entered accurately. The lack of data-reporting regulations and these data 

quality problems limit CSB’s ability to target its resources, identify trends 

and patterns in chemical accidents, and prevent future similar accidents.

CSB has not fully responded to recommendations to resolve its human 

capital problems. In 2002, the FEMA IG found that CSB had a shortfall of 

investigators and had not made hiring them a priority. In addition, it found 

that CSB lacked a central human capital manager, comprehensive strategic 

human capital plan, and performance measures and criteria. The FEMA IG 

recommended that CSB make hiring investigators a top priority and made

several recommendations to strengthen its human capital planning and 

management. 

In response, CSB consolidated human capital responsibilities under a fulltime human resources manager, developed several agencywide goals to 

improve human capital, and hired more investigators; however, we found 

that CSB’s human capital strategy was not comprehensive, lacked a 

detailed action plan for closing the investigator shortfall, did not include 

input from staff investigators, and lacked performance measures—actions 

included in the Strategic Management of Human Capital portion of the 

President’s Management Agenda. 

CSB officials told us they have difficulties attracting and retaining 

investigators. We found that more employees left CSB in fiscal years 2006 

and 2007 than were hired. In fiscal years 2006 and 2007, three of five 

Human Capital Problems 

Persist 

Page 7 GAO-08-864R Chemical Safety Board 
investigators who left were senior investigators with 5 to 7 years of 

experience. Yet CSB hired mostly interns during the same 2 fiscal years. 

CSB hired these interns through the Federal Career Intern program, which 

is designed to attract and retain employees for federal service. However, 

some officials we interviewed, including a board member, investigation 

managers, and investigators, told us intern investigators are encouraged to

leave CSB to gain experience in private industry or to pursue graduate 

degrees. In addition, CSB officials said they offered retention bonuses to 

high-performing mid- and senior-level investigators before they left the 

agency. However, the investigators declined the bonuses because these 

individuals said they received significantly higher compensation from the 

private sector. In addition, CSB officials said they did not offer retention

bonuses to resigning intern investigators because they did not think it 

would make a difference since these individuals would be earning more in 

their new jobs. We found that the agency has not paid a retention bonus to 

any employee since September 2002. Moreover, we found that in fiscal 

year 2006, CSB reprogrammed compensation funds of $627,891 to other 

priorities, including producing safety videos and redesigning its Web site, 

and that in fiscal year 2007, CSB reprogrammed compensation funds of 

$407,383 to similar purchases. 

CSB has not fully responded to recommendations to delegate the authority 

to effectively manage the day-to-day administrative functions to a 

permanent chief operating officer (COO). In March 2002, the FEMA IG 

cited fractured management, a weakened chain of command, and board 

member intervention in routine administration and recommended that the 

board delegate day-to-day administrative functions to a permanent COO to 

ensure continuity of management and accountability. In response to the 

FEMA IG’s recommendation, CSB hired a COO in 2002 to effectively 

manage the day-to-day operations of CSB, but the individual left in 2004. 

The board subsequently eliminated the position and transferred the COO’s 

responsibilities to individual program managers and the board. 

We found that CSB lacks a permanent senior executive to establish 

performance goals, hold program mangers accountable for meeting those 

goals, and demonstrate improvement in the agency’s ability to meet its 

statutory mandate over time. Without a COO, the agency may be unable to

ensure continuity of performance and accountability when board 

members and chairs leave the agency.

CSB board members said that a similar executive director position might 

reduce the administrative responsibilities of the board; however, in 

Accountability and 

Management Problems 

Continue 

Page 8 GAO-08-864R Chemical Safety Board 
comments to GAO, CSB did not support filling a COO or similar position at 

this time because a COO is not likely to provide any additional 

management skills not already represented at the agency. The 

investigation managers and investigators we interviewed generally 

expressed support for reinstating the COO position to improve the 

continuity of administrative management. 

On the basis of our review of CSB’s history and current operations; we 

believe that the independent institutional audit presence of an IG remains 

the best option for ensuring that CSB is accountable to Congress for 

meeting its statutory requirements. We reconsidered the three options for 

oversight we suggested in 2000, which include (1) establishing an in-house 

audit and investigations unit, (2) contracting out for evaluations of its 

operations and programs, and (3) obtaining the services of an existing 

office of inspector general. We determined that the first two options are 

not appropriate for the board for several reasons. The first option—an inhouse audit unit—is not practical because CSB’s history of management 

problems warrants a level of independent oversight that may be difficult to 

achieve by an internal audit function. In addition, the limited staffing that 

would reasonably be allocated to this function at an agency of this size 

would lack the varied expertise needed to address these problems. The 

second option—contracting out for evaluations—is not appropriate 

because of the limitations of contracting in terms of both audit 

independence and the potentially limited duration of the contracting 

relationship. CSB officials told us they prefer the second option because 

they believe CSB’s small size does not justify independent institutional IG 

oversight. In addition, CSB officials said that CSB is classified as one of 54

federal entities defined in the IG Act of 1978 for which the act did not 

provide an IG, but rather required annual reporting of their audit and 

investigative activities to Congress and the Office of Management and 

Budget. However, in our view, the CSB’s long-standing, serious, and 

intractable management problems make it unlikely that the reporting 

requirements for federal entities will ensure that the CSB has an 

appropriate level of oversight to address its management problems. 

Given these factors, in our view IG oversight remains the most appropriate 

oversight option for CSB. Nonetheless, we recognize that there are some 

shortcomings with the current EPA IG’s oversight relationship. First, the 

arrangement is not permanent, a fact that may undermine the continuity of

oversight. Second, EPA IG officials told us they have no plans to conduct

future program evaluations of CSB because they are allocating their 

limited evaluation resources to other priority issues within EPA. However, 

Inspector General 

Oversight Is Still 

Warranted

Page 9 GAO-08-864R Chemical Safety Board 
we do not believe, as CSB asserts, that the EPA IG’s assignment and work 

call into question CSB’s intended independence from EPA. According to 

CSB, CSB independently evaluates and reports to Congress on EPA 

programs in chemical accident prevention, and CSB’s independence from 

EPA was deliberate and carefully considered. By statute, inspectors 

general are independent from the agencies they audit and investigate so 

the EPA IG must maintain his or her independence from EPA officials and 

program employees. With such independence, the IG poses no risk to 

CSB’s independent evaluations of chemical accidents. 

After 10 years of operation, CSB continues to operate in noncompliance 

with its statutory mandates. CSB stresses that it recognizes the importance 

of its investigations to identify root causes of accidental releases and 

recommend regulatory action to prevent such accidental releases, but it is 

not investigating all chemical releases that have a fatality, serious injury, 

substantial property damage, or the potential for a fatality, serious injury, 

or substantial property damage. 

Given the resource constraints on the board that limit its ability to 

investigate all chemical accidents resulting in fatalities, serious injuries, or 

substantial property damage, it is particularly important that CSB better 

leverage its existing resources by using other entities’ work, have the best

available data on which to make decisions on those accidents that are 

most important to investigate, and use all available human capital tools to 

retain staff. Even though CSB has a statutory requirement to issue a 

regulation requiring facilities to report their chemical releases, the board

has resisted requiring such reporting, preferring to rely on alternative 

information sources, such as major news organizations. Requiring facilities 

to report certain information on accidental releases would provide CSB 

with better data than it currently receives from media sources. 

The difficulties that CSB has experienced are largely the result of 

inadequate management accountability for addressing long-standing 

problems and for clearly identifying and attempting to meet CSB’s staff 

requirements to perform investigations of chemical accidents. While we 

recognize that CSB may not have sufficient resources to investigate every 

accident within its purview, as NTSB reports it does, we believe CSB is 

missing opportunities to investigate more accidents and possibly prevent

fatalities, serious injuries, and substantial property damage in the future.

For example, other federal agencies, such as EPA and OSHA, collect 

accident information that, to the extent that the information meets CSB’s 

Conclusions 

Page 10 GAO-08-864R Chemical Safety Board 
data quality standards, could provide additional resources to help the 

board meet its mission. 

We recommend that the chairman of the Chemical Safety Board 

• develop a plan to address the investigative gap and request the 

necessary resources from Congress to meet CSB’s statutory 

mandate or seek an amendment to its statutory mandate; 

• consider using the work of other entities, such as government 

agencies, companies, and contractors (subject to an assessment of 

the quality of their work), to a greater extent to maximize the 

board’s limited resources; 

• improve the quality of its accident-screening database by better 

controlling data entry and periodically sampling accident data to 

evaluate their consistency and completeness; 

• publish a regulation requiring facilities to report all chemical

accidents, as required by law, to better inform the agency of 

important details about accidents that it may not receive from 

current sources; 

• consider reinstating the position of chief operating officer, with 

delegations of responsibility for establishing performance goals, 

holding program mangers accountable for meeting those goals, and 

demonstrating improvement in the agency’s ability to meet it

statutory mandates over time; and 

• use the Strategic Management of Human Capital portion of the 

President’s Management Agenda to provide criteria for developing a 

comprehensive human capital plan, with input from investigators 

that includes specific objectives and performance measures to 

improve accountability for results and to assist the agency in its 

goal of improving its human capital and infrastructure. 

• Congress may wish to consider amending CSB’s authorizing statute or the 

Inspector General Act of 1978 to permanently give EPA’s Inspector 

General the authority to serve as the oversight body for the agency. 

• As Congress prepares the appropriation of the EPA Inspector General, it 

may wish to consider providing the Inspector General with appropriations 

and staff allocations specifically for the audit function of CSB via a direct 

line in the EPA appropriation. 

Recommendations for 

Executive Action 

Matters for 

Congressional 

Consideration 

Page 11 GAO-08-864R Chemical Safety Board 
We provided a draft of our report to CSB for its review and comment. We 

received written comments from CSB’s Chairman and Chief Executive 

Officer (CEO). These comments and our detailed response to them are 

presented in enclosure III. CSB also provided technical comments, which 

we have incorporated into the report as appropriate. 

Regarding the six specific recommendations we made in the report, CSB 

generally concurred with four and disagreed with two. CSB also disagreed 

with both matters for congressional consideration we identified in the 

report. CSB generally concurred that it should (1) consider using the work 

of other entities to maximize the board’s limited resources, (2) improve 

the quality of its accident-screening database, (3) consider reinstating the

position of chief operating officer, (4) use the Strategic Management of 

Human Capital portion of the President’s Management Agenda as a guide 

for developing a comprehensive human capital plan. 

CSB did not generally concur with our recommendation to develop a plan to 

address the investigative gap and request the necessary resources from 

Congress to meet its statutory mandate. The agency reports that it will seek 

additional investigation resources and “will draft a plan for obtaining 

information on additional chemical accidents occurring in the United States, 

and clearly set forth a risk-based approach to accident selection and 

investigation.” However, it does not commit to meet CSB’s statutory mandate 

for investigating chemicalreleases, citing its view that “CSB has not construed 

the agency’s authorizing statute as requiring investigation of every chemical 

accident involving a fatality, serious injury, or substantial property damage, or 

the potential for such consequences.” CSB has not explained the basis for its 

interpretation. The 1990 Clean Air Act Amendments establishing the CSB states 

“[t]he Board shall investigate (or cause to be investigated)...any accidental 

release resulting in a fatality, serious injury or substantial property damage.” 

Further, the act states that “[i]n no event shall the Board forgo an investigation

where an accidental release causes a fatality or serious injury among the 

general public, or had [sic] the potential to cause substantial property damage 

or a number of deaths or injuries among the general public.” As noted in our 

briefing, this language clearly identifies which accidental releases CSB is 

required to investigate; that is, investigations are required for all accidental

releases that result, or have the potential to result, in a fatality, serious injury, or

substantial property damage. Although CSB did not agree with this 

interpretation, the agency stated that it would work with Congress to clarify the 

issue of its statutory mandate and, if appropriate, seek an amendment to CSB’s 

authorizing statute. We believe that CSB’s willingness to work with Congress to 

clarify its statutory mandate is a step in the right direction. However, we 

Agency Comments 

and Our Evaluation 

Page 12 GAO-08-864R Chemical Safety Board 
continue to believe the current law is clear; CSB should meet its current 

mandate or seek an amendment to its authorizing statute. 

CSB disagreed with our matter for congressional consideration to consider 

amending CSB’s authorizing statute or the IG Act of 1978 to permanently

give EPA’s Inspector General the authority to serve as the oversight body 

for the agency. CSB said that while the EPA IG is one option for oversight,

other offices of inspector general are also available, some of which may be 

more appropriate for the role. CSB also questioned the independence of

the EPA IG, since CSB issues recommendations to EPA program offices. 

We assessed other options for oversight that we had considered in our 

2000 report, as well as options presented to us by CSB. We understand 

CSB’s concerns; however, the IG Act requires inspectors general to be 

independent from the agencies they audit and investigate. The EPA IG has 

expertise involving the chemical management issues that the Board is 

charged with investigating, has gained knowledge of CSB’s operations and 

activities in providing the Board with oversight over the past several years, 

and, like other IGs, has the requisite independence provided by the IG Act 

of 1978 necessary for reviewing and making recommendations to address 

long-standing problems in the Board’s management performance. As a 

result, using the EPA IG does not pose a risk to CSB’s independent 

evaluation of chemical accidents. 

CSB also disagreed with our matter for congressional consideration to 

provide the EPA IG with appropriations and staff allocations specifically

for the audit of CSB via a direct line in the EPA appropriation. CSB said 

GAO did not adequately consider different oversight options for CSB and 

that oversight should be tailored to the size of the agency. CSB also noted

that it currently obtains its financial and information security audits for 

about $60,000 a year. We believe that all significant federal programs and 

entities should be subject to oversight by IGs who can provide sound 

independent audits of all significant federal operations and activities. 

Given the management problems that our audit revealed, the need for 

independent IG oversight at CSB is especially pressing. Further, financial 

and information security audits are not a substitute for the oversight of 

program management provided by an independent IG. 

We are sending copies of this report to the Chairman and CEO of the 

Chemical Safety and Hazard Investigation Board, appropriate 

congressional committees, and other interested parties. We will also 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. 

Page 13 GAO-08-864R Chemical Safety Board 
If you or your staff have any questions about this report, please contact me 

at 202-512-3841 or stephensonj@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Major contributors to this report were Ed Kratzer, Assistant 

Director; Vanessa Dillard; Brian M. Friedman; Angela Miles; Alison O’Neill; 

Michael Sagalow; Rebecca Shea; John C. Smith; and Jeanette Soares. 

John B. Stephenson 

Director, Natural Resources 

and Environment 

Enclosures 

Page 14 GAO-08-864R Chemical Safety Board 
Congressional Addressees 

The Honorable Dianne Feinstein 

Chairman 

The Honorable Wayne Allard 

Ranking Member 

Subcommittee on Interior, Environment, and Related Agencies 

Committee on Appropriations 

United States Senate 

The Honorable Norman D. Dicks 

Chairman 

The Honorable Todd Tiahrt 

Ranking Member 

Subcommittee on Interior, Environment, and Related Agencies 

Committee on Appropriations 

House of Representatives 

Page 15 GAO-08-864R Chemical Safety Board 
Enclosure I: Scope and Methodology 

Page 16 GAO-08-864R Chemical Safety Board 

Enclosure I: Scope and Methodology 

To perform our review, we analyzed authorizing statutes, regulations, 

legislative history, and GAO and office of inspector general (IG) reports, 

and other literature. We also reviewed and analyzed the Chemical Safety 

and Hazard Investigation Board’s (CSB) strategic plan, human capital 

report, policies and procedures, and other program documents, and 

compared them to similar documents from the National Transportation 

Safety Board (NTSB). In addition, we reviewed a subset of CSB’s accident

screening database that included two variables CSB uses to rank the 

seriousness of an accident—fatalities and injuries and the narratives 

explaining these accidents. We also consulted GAO’s guidance on 

management best practices, human capital, data reliability, and oversight.

In addition, we interviewed officials from CSB, officials from past and 

current IGs. We also consulted NTSB officials and GAO experts on 

management, data reliability, human capital, and oversight issues. 

We did not evaluate the quality of CSB’s investigative products issued to 

date, or the quality and effectiveness of its reports, recommendations, and 

promotion of preventive actions, because these evaluations were outside 

the scope of our mandate and are not relevant to the findings and 

conclusions of this engagement. We also did not conduct a detailed 

evaluation of the oversight arrangements for the other 53 federal entities 

for comparison with CSB because the continuing management problems 

found in our audit highlight the need for IG oversight. 

We conducted this performance audit from October 2007 to May 2008 in 

accordance with generally accepted government auditing standards. Those 

standards require that we plan and perform the audit to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objectives. We believe that the evidence 

obtained provides a reasonable basis for our findings and conclusions 

based on our audit objectives. We determined that the agency’s accident 

screening database is sufficiently reliable for the purpose of making broad 

estimates of the total number of accidents and accidents with fatalities. 

Among the data’s limitations is the lack of quality controls to ensure that 

data are accurate and complete, especially with respect to fatalities. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 17 GAO-08-864R Chemical Safety Board 

Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff 

Chemical Safety Board: 

Improvements in Management 

and Oversight Are Needed 

Briefing to the Subcommittees on 

Interior, Environment, and Related 

Agencies, Committee on Appropriations, U.S. Senate

U.S. House of Representatives
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

2

Background

• The Chemical Safety and Hazard Investigation Board (CSB) 

is an independent agency that was created under the Clean 

Air Act Amendments of 1990 and began operating in 1998.

The act directed CSB to

• investigate and report on the cause or probable cause of

any accidental chemical releases resulting in a fatality, a 

serious injury, or substantial property damage;

• make recommendations to reduce the likelihood or

consequences of accidental chemical releases and 

propose corrective measures; and

• establish regulations for reporting accidental releases.

Page 18 GAO-08-864R Chemical Safety Board 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 19 GAO-08-864R Chemical Safety Board 

3

Background

• Congress modeled CSB after the National Transportation Safety

Board (NTSB), which has a similar mission.

• Like NTSB, CSB has no enforcement authority and a limited

regulatory role. 

• As outlined in the statute, CSB is to be managed by a five-member

board. Currently the board has one vacancy.

• In fiscal year 2009, CSB requested $10.6 million and 47 staff.

• In fiscal year 2000, CSB requested $12.5 million and 60 staff.

• Prior year appropriations and on-board staff levels include 

• fiscal year 2008, $9.4 million and 39 staff (as of 1/30/2008);

• fiscal year 2006, $9.2 million and 41 staff (as of 9/30/2006);

• fiscal year 2004, $8.2 million and 40 staff (as of 9/30/2004); and

• fiscal year 2000, $8.0 million and 27 staff (as of 6/15/2000).
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 20 GAO-08-864R Chemical Safety Board 

4

Background

• In 2000, GAO reported problems with CSB’s governance, 

management, policies, and procedures and recommended, among 

other things, that CSB obtain the services of an existing office of 

inspector general (IG).

• Since fiscal year 2001, three existing IGs have provided oversight to 

CSB: Federal Emergency Management Agency (FEMA), the 

Department of Homeland Security (DHS), and the U.S.

Environmental Protection Agency (EPA). EPA’s IG currently

provides oversight.

• From fiscal year 2002 through 2007, inspectors general have made 

32 recommendations to address problems in management

accountability and control, human capital management, compliance

with its statutory requirements, and other issues. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 21 GAO-08-864R Chemical Safety Board 

5

Objectives

• You asked us to examine

1. how CSB has responded to GAO and IG

recommendations regarding CSB’s investigative gap,

data quality problems, human capital problems, and 

accountability and management problems for meeting its 

mission requirements and

2. the merits of the current oversight approach—using an 

existing office of inspector general—and other 

alternative approaches to oversight.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 22 GAO-08-864R Chemical Safety Board 

6

Scope and Methodology

• To answer these questions, we reviewed

• authorizing statutes, regulations, legislative history and GAO and IG

reports, and other literature; 

• CSB’s accident screening database for fiscal year 2006 and fiscal year 

2007;

• CSB’s strategic plan, human capital report, and other program

documentation such as policies and procedures;

• similar program documents from NTSB for comparison to CSB 

documents;

• GAO guidance pertaining to management best practices, human 

capital, data reliability, and oversight; and

• The mission and oversight arrangements for 54 federal entities, including CSB, as defined by the Inspector General Act of 1978.

• We did not review or evaluate the quality or effectiveness CSB’s products, recommendations or preventive actions as that was outside the scope of

our mandate and not relevant to this engagement’s findings and 

conclusions.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 23 GAO-08-864R Chemical Safety Board 

7

Scope and Methodology

• We also interviewed officials from CSB and past and current IGs and

consulted GAO experts on management, data reliability, human capital, 

and oversight issues.

• We conducted this performance audit from October 2007 to May 2008 in

accordance with generally accepted government auditing standards. Those 

standards require that we plan and perform the audit to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objectives. We believe that the evidence

obtained provides a reasonable basis for our findings and conclusions

based on our audit objectives. We determined that the agency’s accidentscreening database is sufficiently reliable for the purpose of making broad 

estimates of the total number of accidents and accidents with fatalities. 

Among the data’s limitations is the lack of quality controls to ensure that 

data are accurate and complete, especially with respect to fatalities.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 24 GAO-08-864R Chemical Safety Board 

8

Results in Brief

• CSB has implemented some GAO and IG recommendations related to improving its 

operating policies and procedures since we last reported in July 2000. However,

CSB has not fully addressed several critical recommendations, and problems in

governance, management, and oversight persist. Specifically, CSB has not fully

responded to key recommendations related to (1) investigating more accidents that

meet statutory requirements triggering the CSB’s responsibility to investigate, (2) 

improving the quality of its accident data, (3) resolving human capital problems, and 

(4) ensuring accountability and continuity of management.

• In our view, independent oversight from an existing IG remains the most effective 

way to help CSB address its continuing problems, provided that the arrangement is

made permanent and funding is provided to the IG for the function. CSB officials

disagreed based on the agency’s small size and its existing annual reporting 

requirements to Congress and the Office of Management and Budget.

• Therefore

• We are making recommendations to the Chair of CSB to address continuing 

problems with governance and management.

• We are proposing matters for congressional consideration to address

continuing problems with oversight.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 25 GAO-08-864R Chemical Safety Board 

9

The investigative gap persists

• CSB has not fully responded to recommendations to address its

investigative gap—the difference between the number of accidents

it investigates and the accidents that meet statutory criteria 

triggering CSB’s responsibility to investigate. 

• Initial problem: Using fiscal year 2002 data, the DHS IG reported in 

fiscal year 2004 that of the 613 accidents CSB screened, about 294 

met statutory criteria, and CSB deployed investigators to 4. 

Moreover, while acknowledging that CSB lacked the resources to

investigate all 294 accidents, the IG reported that CSB did not have

a plan for reporting to Congress on the number and type of 

accidents it was not able to investigate or a plan for narrowing the 

investigative gap. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 26 GAO-08-864R Chemical Safety Board 

10

The investigative gap persists

• IG’s recommendation: The DHS IG recommended that CSB develop a plan

to describe and address the investigative gap and include the information 

in future budget submissions to Congress and OMB. 

• How CSB responded: Two years after the IG made the recommendation,

CSB prepared a onetime report to Congress in 2006. The report described 

14 accidents occurring in 1 year that it said it would have investigated if it 

had had the resources. However, the report did not describe a plan to

address the investigative gap identified by DHS IG. 

• CSB has not repeated this report; rather, it included less detailed 

information in subsequent budget justifications to Congress. 

• CSB officials told us that congressional staff did not request 

subsequent annual reports with this level of detail. 

• CSB officials also said the agency lacks the resources to investigate

more than a small percentage of the accidents that meet statutory 

criteria triggering the board’s responsibility to investigate.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 27 GAO-08-864R Chemical Safety Board 

11

The investigative gap persists

• Problem remaining: CSB continues to underestimate the number of 

accidents it would need to investigate to meet statutory

requirements. In addition, it has not significantly narrowed its 

investigative gap—investigating about 6 accidents each year from 

fiscal years 2004 through 2007. Moreover, CSB has not developed

a long-term plan for reporting to Congress on the scope and 

magnitude of its investigative gap or a detailed strategy to address

it. Therefore

• CSB continues to fall short of its statutory mandate, and 

accidents that involve fatalities, serious injuries, and substantial 

property damage go uninvestigated.

• Congress does not have accurate or comprehensive 

information about CSB’s investigative gap or the resources it 

would need to close it.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 28 GAO-08-864R Chemical Safety Board 

12

The investigative gap persists

• In fiscal year 2007, CSB investigated less than 1 percent (5 of 920) 

of accidents of which it was notified.

• Examples of accidents in fiscal years 2006 and 2007 that CSB did

not investigate include

• An oil well explosion that killed 3 teens.

• A methanol flash fire at a school that injured 8 students and 

their teacher. Three students and the teacher were hospitalized 

for burns on their upper torsos, faces, and hands.

• A natural gas well explosion that killed 1 worker and forced 

hundreds of residents out of their homes for hours.

• A propane explosion that killed 3 workers and injured 47.

• A waste-processing plant that released noxious chemicals and 

may have sickened more than 200 people.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 29 GAO-08-864R Chemical Safety Board 

13

The investigative gap persists
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 30 GAO-08-864R Chemical Safety Board 

14

The investigative gap persists

• CSB and NTSB are both required to investigate all accidents meeting

certain criteria. NTSB is required to investigate (1) all civil aviation

accidents; (2) all pipeline accidents in which there is a fatality, substantial 

property damage, or significant injury to the environment; (3) all railroad 

accidents in which there is a fatality or substantial property damage, or that 

involves a passenger train; and (4) certain major marine casualties.

Likewise, CSB is required to investigate all accidental chemical releases

into the air from stationary sources that cause a fatality, serious injury, or

substantial property damage. NTSB does have discretion in selecting 

which highway and "other modes of transportation" accidents to 

investigate. CSB's authorizing statute does not give it any discretion in 

selecting which accidents to investigate.

• While NTSB’s budget is approximately 8 times CSB’s budget, NTSB 

investigates 250 times as many accidents.

• Figure 1 describes the annual budget and the number of investigations 

CSB and NTSB started in fiscal year 2006.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 31 GAO-08-864R Chemical Safety Board 

15

The investigative gap persists

Figure 1. CSB and NTSB Number of Accident Investigations Initiated and Budget, fiscal year 2006
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 32 GAO-08-864R Chemical Safety Board 

16

The investigative gap persists

• Both CSB’s and NTSB’s statutes allow the use of investigations performed 

by other agencies. Unlike CSB, NTSB uses its authority to solicit 

investigative work performed by others when resources or other 

considerations prevent it from deploying to accident sites. In all cases, overall investigative control, including determination of probable cause, 

rests with NTSB. 

• NTSB's size prevents it from being on-site for many aviation investigations; therefore, the agency conducts limited investigations in which NTSB

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

but rather correspond with local officials, rescue response units, Federal

Aviation Administration personnel, and other persons and organizations

that might have knowledge of the accident. The different types of NTSB

aviation investigations are described in attachment 2.

• Similar to NTSB, CSB has the authority to use information gathered by local officials, rescue response units, Occupational Safety & Health 

Administration (OSHA) and EPA personnel, and other persons and 

organizations to prepare its reports and thereby expand its knowledge base

of chemical accidents while operating with limited resources. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 33 GAO-08-864R Chemical Safety Board 

17

The investigative gap persists

• CSB has memorandums of understanding with OSHA and EPA that 

indicate in certain instances, CSB may decide not to send an

investigation team to the site of a chemical incident but may collect 

incident information from EPA, OSHA, or other on-site agencies

compiled in the course of their own actions.

• Like NTSB, CSB has the ability to issue accident briefs, in addition

to more detailed accident reports. See attachment 3 for a 

description of the types of NTSB accident reports.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 34 GAO-08-864R Chemical Safety Board 

18

The investigative gap persists

• We reported in 2000 that CSB discontinued its limited, office-based

review program that used investigative reports prepared by other

organizations that respond to accidents. While the limited review

program was less resource intensive than full investigations, board 

officials told us that they terminated this practice in 1999 because it 

conflicted with the board’s independence by having the board rely

on the work of other agencies.

• In contrast, NTSB does conduct limited, office-based investigations

that rely on the work of other entities. We reported in 2006 that 

while NTSB’s use of others’ work may present some challenges, it

appears to be working well. Performing data reliability

assessments of important information based on the work of others

is a generally accepted means used by federal and private audit 

organizations. CSB could likewise use existing reports and studies

rather than performing comprehensive investigations of its own.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 35 GAO-08-864R Chemical Safety Board 

19

Data quality problems continue

• CSB has not fully responded to IG recommendations to

improve the quality of its accident data.

• Initial problem: CSB maintains an accident-screening 

database to report to Congress and the public on the

number of chemical accidents it identifies and selects 

for investigation. However, the Department of Homeland 

Security (DHS) IG reported that CSB had inadequate 

control over the quality of its data and needed to monitor

for completeness, accuracy, timeliness, and usefulness.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 36 GAO-08-864R Chemical Safety Board 

20

Data quality problems continue

• The IG’s recommendation: The DHS IG recommended that CSB 

fulfill its statutory requirement to publish a regulation for receiving 

information from facilities on their chemical accidents. The IG also

recommended that CSB develop a long-term strategy to address

the shortfall in national chemical accident database quality.

• How CSB responded: CSB has not issued the regulation and has 

no plans to do so. According to CSB officials, the current system of 

monitoring media reports, searching the Web, and obtaining 

accident reports from NTSB and other sources is sufficient.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 37 GAO-08-864R Chemical Safety Board 

21

Data quality problems continue

• Problem remaining: According to CSB officials, they have resolved 

the IG’s concerns about data quality; however, we found that CSB

still has not published a data-reporting regulation and lacks a longterm strategy to improve quality controls, and the data remain 

somewhat inaccurate and incomplete. For example, when we

analyzed a subset of accidents in the database involving fatalities

and injuries, we found at least five accidents (about 6 percent)

where fatalities were not correctly recorded in the database. We

also found seven accidents (about 4 percent) where data on injuries

were missing as a result of incomplete data entry. Moreover, CSB

does not have procedures to ensure that data were entered 

accurately.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 38 GAO-08-864R Chemical Safety Board 

22

Data quality problems continue

• CSB officials maintain that publishing a regulation to obtain information

from facilities on their chemical accidents is not necessary because the 

information the board already receives is sufficient. Without a regulation,

CSB relies primarily on the media, such as online newspapers and

television, to learn about chemical accidents. It is likely that information

reported by facilities would be a better source than CSB’s current practice

of relying mostly on the media. Information provided in media sources may 

contain errors and not include the kind of information CSB needs to make

decisions about which accidents to investigate or provide the agency with 

the kind of information needed for trend analysis and prevention outreach.

• In addition, the lack of quality controls of CSB’s accident database has 

contributed to data problems that could limit CSB’s ability to accurately 

report information on the investigative gap to Congress, target its

resources, identify trends and patterns in chemical accidents, and prevent

future similar accidents.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 39 GAO-08-864R Chemical Safety Board 

23

Human capital problems persist

• CSB has not fully responded to recommendations to

resolve its human capital problems.

• Initial problem: In 2002, the FEMA IG identified

weaknesses in CSB’s human capital management, 

particularly that it had a shortfall of investigators, had 

not made hiring investigators a top priority, and that it

lacked a central human capital manager, a

comprehensive strategic human capital plan, and 

performance measures and criteria. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 40 GAO-08-864R Chemical Safety Board 

24

Human capital problems persist

• IG’s recommendation: The FEMA IG recommended that 

CSB make hiring a top priority and made several 

recommendations to strengthen its human capital

planning and management. 

• How CSB responded: CSB consolidated human capital 

responsibilities under a full-time human resources 

manager, developed several agencywide strategies that

included goals to improve human capital, hired more

investigators, and established a remote office in Denver 

for one senior investigation manager. However, CSB 

officials acknowledged difficulties in attracting senior 

investigators to live in the District of Columbia and in

retaining intern investigators.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 41 GAO-08-864R Chemical Safety Board 

25

Human capital problems persist

• Problem remaining: CSB’s human capital strategy was not comprehensive, 

lacked a detailed action plan for closing the investigator shortfall, did not 

include input from staff investigators, and lacked performance measures—

actions included in the Strategic Management of Human Capital portion of

the President’s Management Agenda. Therefore

• CSB’s shortfall in investigators and problems retaining staff continue, 

limiting the number of accidents CSB could investigate regardless of

resources. 

• According to a board member and some investigation managers and 

investigators we interviewed, intern investigators are encouraged to 

leave CSB in order to gain private industry experience or to pursue a 

terminal graduate degree. Encouraging interns to leave federal 

service for private industry experience does not follow the purpose of 

the Federal Career Intern program, which is designed to attract and 

retain employees for federal service.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 42 GAO-08-864R Chemical Safety Board 

26

Human capital problems persist

• More employees 

left CSB in fiscal 

years 2006 and 

2007 than were 

hired, indicating a

possible problem

with retention. 

• CSB officials 

acknowledge a 

problem with hiring and retention; however, the 

agency has not 

given a retention

bonus to an 

employee since 

2002.

Figure 2: Number of CSB Hires and Separations Fiscal Years 2006-2007
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 43 GAO-08-864R Chemical Safety Board 

27

Human capital problems persist

• In fiscal years 2006 and 

2007, 3 of 5 investigators

who left CSB were senior 

investigators with 5-7

years of experience. Yet 

CSB hired mostly interns

during the same 2 fiscal

years. 

• In fiscal years 2006 and 

2007, 4 of 11 staff hired 

were investigators. Three

of the 4 investigators CSB 

hired were interns. CSB

officials told us that they

can hire interns more 

easily than senior 

investigators.

Figure 3: CSB Investigators and Other Staff Hired, Fiscal Years 2006–2007
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 44 GAO-08-864R Chemical Safety Board 

28

Human capital problems persist

• According to CSB officials, an intern does not replace an 

experienced senior investigator; after converting to a permanent

position from the intern position, it takes 3 to 5 years to become 

fully qualified.

• However, CSB officials said retaining interns is a challenge and

noted that two of four intern investigators hired in fiscal years 2004 

and 2005 left CSB and one transferred to another office. 

• If CSB had retained intern investigators hired in fiscal years 2004 

and 2005, it would have two additional investigators with 3 years of 

experience in fiscal year 2008.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 45 GAO-08-864R Chemical Safety Board 

29

Human capital problems persist

• CSB has not fully used strategies available to federal agencies that 

are designed to recruit or retain staff, such as

• Federal Career Intern Program–The purpose of the federal 

intern program is to convert successful interns to permanent 

employees. The majority of interns have left CSB.

• Education and training assistance–Intern investigators

interested in pursuing a graduate degree might remain at CSB

if the agency offered support for tuition and additional training.

• Retention bonuses–Federal agencies may pay a retention 

incentive to a current employee if the agency determines that it

is essential to retain the employee. CSB has not given any

employee a retention bonus since September 2002.

• Remote offices–CSB has not expanded the use of remote 

offices. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 46 GAO-08-864R Chemical Safety Board 

30

Human capital problems persist

• In fiscal year 2006, CSB reprogrammed compensation funds of 

$627,891 to other priorities, such as safety videos and redesigning 

a Web site. In fiscal year 2007, CSB reprogrammed compensation

funds of $407,383 to similar purchases.

• Had CSB made resolving human capital problems a top priority, 

these funds could have been used during the year for recruitment

and retention bonuses, education and training assistance, and 

student loan repayment to hire and retain investigators.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 47 GAO-08-864R Chemical Safety Board 

31

Accountability and management 

problems continue

• CSB has not delegated the authority to effectively manage 

the day-to-day administrative functions to a permanent chief 

operating officer (COO) to ensure continuity of management

and accountability.

• Initial problem: Between fiscal years 2000 and 2002, CSB did 

not have a permanent COO or a fully staffed board with a

chair. Uncertainties surrounding the acting COO’s role and 

authority resulted in fractured management, a weakened 

chain of command, and board member intervention in routine 

administration. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 48 GAO-08-864R Chemical Safety Board 

32

Accountability and management 

problems continue

• IG’s recommendation: The IG recommended that the board delegate to the 

COO the authority to effectively manage the day-to-day operations of CSB. 

• How CSB responded: CSB hired a COO in June 2002, but the individual 

left after 2 years. The board subsequently eliminated the position and 

transferred the COO’s responsibilities to individual program managers and 

the board. 

• CSB board members said that a COO or similar executive director

position might reduce the administrative responsibilities of the board, however, the CSB Chairman said a COO is unlikely to provide any additional management skills not already represented at the agency. Two investigation managers and two investigators we interviewed 

generally expressed support for reinstating the COO position to 

improve the continuity of administrative management.

• EPA IG officials told us that there was support for the COO position 

among the CSB employees (former and current) they interviewed 

during their investigation in fiscal year 2007. These CSB employees 

indicated that they preferred how things operated when the COO was

present. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 49 GAO-08-864R Chemical Safety Board 

33

Accountability and management 

problems continue

• Problem remaining: CSB continues to operate without a permanent 

COO or a fully staffed board. Therefore

• CSB lacks a permanent senior executive with responsibility to 

establish performance goals, hold program managers

accountable for meeting those goals, ensure there is a shared 

vision among board members and managers, and demonstrate 

improvement in the agency’s ability to meet it statutory mission

over time.

• CSB may not be able to ensure continuity of performance and 

accountability when board members and chairs leave the 

agency.

• Regardless of the board’s staffing status, GAO has

recommended in the past that employing a COO would provide 

long-term attention and focus on management issues. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 50 GAO-08-864R Chemical Safety Board 

34

IG oversight is still warranted

• CSB’s history suggests that an IG’s continued independent

institutional audit presence is the best option for ensuring 

that CSB is more accountable to Congress for meeting its

public safety mission and statutory requirements.

As we reported in 2000, three options for oversight include

1. establishing an in-house audit and investigations unit,

2. contracting out for evaluations of its operations and 

programs, and

3. obtaining the services of an existing office of inspector 

general.

• We do not believe options 1 and 2 are appropriate for the 

board for several reasons.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 51 GAO-08-864R Chemical Safety Board 

35

IG oversight is still warranted

• Option 1, an in-house audit unit, does not appear to be practical 

because CSB’s history of management problems warrants a level 

of independent oversight that may be difficult to achieve by an 

internal audit function. In addition, the limited staffing that would 

reasonably be allocated to this function at an agency of this size

would lack the varied expertise need to address these problems.

• Option 2, contracting out for evaluations, also does not appear to 

be appropriate because of the limitations of contracting in terms of

both audit independence and the potentially limited duration of the 

contracting relationship—which would not provide the continuity of 

oversight needed to address CSB’s long-standing management 

problems. 
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 52 GAO-08-864R Chemical Safety Board 

36

IG oversight is still warranted

• CSB officials told us they prefer option 2 because IG oversight is

inappropriate for an agency of CSB’s small size. CSB officials told

us that CSB is currently classified as 1 of 54 federal entities, as

defined by the IG Act of 1978, for which the act did not provide an 

IG.

• Under the IG Act, federal entities are required to report annually to Congress and the Office of Management and Budget on 

whether an IG has been established or what other actions the 

federal entity took to otherwise ensure that audits of its

programs and operations were conducted. 

• CSB officials also told us that the IG Act provides a reasonable and 

responsible level of oversight for federal entities and requested that 

CSB be treated similarly to these entities. However, in our view, CSB’s long-standing, serious, and intractable management 

problems make it unlikely that this reporting requirement alone will

ensure that the CSB has an appropriate level of oversight 

necessary to address its management problems.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 53 GAO-08-864R Chemical Safety Board 

37

IG oversight is still warranted

• Given CSB’s management problems, the fact that other federal 

entities lack an IG should not determine whether CSB should have

an IG. In any event, by statute some other federal entities do have

another agency’s IG assigned to provide them with oversight. For

example, the IG of the Department of Agriculture is assigned to 

provide oversight to the Delta Regional Authority. (Att. 1 provides

the list of 54 federal entities, as defined by the IG Act of 1978, and 

identifies 4 that have a critical safety mission.)
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 54 GAO-08-864R Chemical Safety Board 

38

IG oversight is still warranted

• Option 3, obtaining the services of an existing IG office, appears to 

be the most appropriate oversight arrangement given the serious,

intractable management problems at CSB.

• We believe that all significant federal programs and entities should 

be subject to oversight by IGs who can provide sound independent

audits of all significant federal operations and activities. Given the 

management problems that our audit revealed, the need for

independent IG oversight is especially pressing.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 55 GAO-08-864R Chemical Safety Board 

39

IG oversight is still warranted

• While we believe that IG oversight remains the most appropriate oversight 

option, we found some shortcomings with the current EPA IG’s oversight relationship: 

• The current IG arrangement is not permanent, a fact that may undermine the continuity of oversight; the EPA IG is assigned to serve 

as CSB’s IG in annual appropriation bills.

• EPA IG officials told us they have no plans to conduct program

evaluations of CSB in fiscal year 2008 because they are allocating their limited evaluation resources to other priorities within EPA. 

• However, we do not believe, as CSB asserts, that the EPA IG’s assignment 

and work call into question CSB’s intended independence from EPA. 

According to CSB, CSB independently evaluates and reports to Congress

on EPA programs in chemical accident prevention and CSB’s

independence from EPA was deliberate and carefully considered. By statute, inspectors general are independent from the agencies they audit 

and investigate so the EPA IG must maintain his or her independence from

EPA officials and program employees. With such independence, the IG 

poses no risk to CSB’s independent evaluations of chemical accidents.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 56 GAO-08-864R Chemical Safety Board 

40

Conclusions

• After 10 years of operation, CSB continues to operate in

noncompliance with its statutory mandates.

• CSB stresses that it recognizes the importance of its

investigations to identify root causes of accidental releases and 

recommend regulatory action to prevent such accidental 

releases but is not investigating all chemical accidents that 

have a fatality, serious injury, property damage, or the potential

for a fatality, serious injury, or property damage. 

• While we recognize that CSB may not have sufficient resources 

to investigate every accident within its purview, as NTSB

reports it does, we believe CSB is missing opportunities to 

investigate more accidents and possibly prevent fatalities, 

serious injures, and substantial property damage in the future

by not using the work of other entities.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 57 GAO-08-864R Chemical Safety Board 

41

Conclusions

• In addition, given the resource constraints on the board that limit its

ability to investigate all chemical accidents resulting in fatalities, serious injuries, or substantial property damage, it is particularly important that CSB have the best available data on which to make

decisions on those accidents that are most important to investigate. 

Even though CSB has a statutory requirement to issue a regulation 

requiring facilities to report their chemical releases, the board has

resisted requiring such reporting, preferring to rely on alternative 

information sources, such as major news organizations.

• The difficulties that CSB has experienced in meeting its mission are

largely the result of inadequate management accountability for 

addressing long-standing problems and for clearly identifying and 

attempting to meet CSB’s staff requirements to perform investigations

of chemical accidents. In this regard, CSB has functioned without a 

permanent chief operations officer with responsibility for holding CSB’s

managers accountable for their management activities and has not

developed a comprehensive human capital strategy to improve its 

efforts to investigate chemical accidents in line with the board’s

statutory responsibilities.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 58 GAO-08-864R Chemical Safety Board 

42

Recommendations to the Agency

• We recommend that the chairman of the Chemical Safety Board 

• develop a plan to address the investigative gap and request 

the necessary resources from Congress to meet CSB’s

statutory mandate or seek an amendment to its statutory

mandate;

• consider using the work of other entities, such as government 

agencies, companies, and contractors (subject to an 

assessment of the quality of their work) to a greater extent to 

maximize the board’s limited resources; and

• improve the quality of its accident-screening database by

better controlling data entry and periodically sampling accident

data to evaluate their consistency and completeness.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 59 GAO-08-864R Chemical Safety Board 

43

Recommendations to the Agency

• Publish a regulation requiring facilities to report all chemical

accidents, as required by law, to better inform the agency of 

important details about accidents that it may not receive from 

current sources.

• Consider reinstating the position of chief operating officer, with 

the delegation of responsibility for establishing performance 

goals, holding program mangers accountable for meeting those 

goals, and demonstrating improvement in the agency’s ability to 

meet its statutory mandates over time.

• Use the Strategic Management of Human Capital portion of the 

President’s Management Agenda to provide criteria for

developing a comprehensive human capital plan, with input 

from investigators, that includes specific objectives and 

performance measures to improve accountability for results and 

to assist the agency in its goal of improving its human capital 

and infrastructure.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 60 GAO-08-864R Chemical Safety Board 

44

Matters for Congressional Consideration

• Congress may wish to consider amending CSB’s organic

statute or the Inspector General Act of 1978 to permanently 

give EPA’s Inspector General the authority to serve as the 

oversight body for the agency.

• As Congress prepares the appropriation of the EPA Inspector 

General, it may wish to consider providing the Inspector 

General with appropriations and staff allocations specifically 

for the audit function of CSB via a direct line in the EPA 

appropriation.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 61 GAO-08-864R Chemical Safety Board 

45

Attachment 1—Federal entities, as defined by 

the IG Act of 1978

1. Chemical Safety and Hazard Investigation Board*

2. Defense Nuclear Facilities Safety Board*

3. National Transportation Safety Board*

4. Nuclear Waste Technical Review Board*

5. Advisory Council on Historic Preservation

6. African Development Foundation

7. American Battle Monuments Commission

8. Architectural and Transportation Barriers Compliance Board

9. Armed Forces Retirement Home

10. Barry Goldwater Scholarship and Excellence in Education Foundation 

11. Christopher Columbus Fellowship Foundation

12. Commission for the Preservation of America's Heritage Abroad

13. Commission of Fine Arts 

14. Commission on Civil Rights

15. Committee for Purchase from People Who Are Blind or Severely Disabled 

*Has a public safety mission
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 62 GAO-08-864R Chemical Safety Board 

46

Attachment 1—Federal entities, as defined by 

the IG Act of 1978

16. Court of Appeals for Veterans Claims

17. Court Services and Offender Supervision Agency for DC

18. Delta Regional Authority

19. Farm Credit System Insurance Corporation 

20. Federal Financial Institutions Examination Council

21. Federal Mediation and Conciliation Service

22. Federal Mine Safety and Health Review Commission

23. Federal Retirement Thrift Investment Board

24. Harry S. Truman Scholarship Foundation

25. Inter-American Foundation

26. Institute of American Indian and Alaska Native Culture and Arts Development

27. Institute of Museum and Library Services

28. James Madison Memorial Fellowship Foundation

29. Japan-U.S. Friendship Commission

30. Marine Mammal Commission
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 63 GAO-08-864R Chemical Safety Board 

47

Attachment 1—Federal entities, as defined by 

the IG Act of 1978

31. Merit Systems Protection Board

32. Millennium Challenge Corporation 

33. Morris K. Udall Scholarship and Excellence in National Environmental Policy Foundation

34. National Capital Planning Commission

35. National Commission on Libraries and Information Science

36. National Council on Disability

37. National Mediation Board

38. Neighborhood Reinvestment Corporation

39. Occupational Safety and Health Review Commission

40. Office of Government Ethics

41. Office of Navajo and Hopi Indian Relocation

42. Office of Special Counsel

43. Overseas Private Investment Corporation 

44. Presidio Trust

45. Selective Service System
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 64 GAO-08-864R Chemical Safety Board 

48

Attachment 1—Federal entities, as defined by 

the IG Act of 1978

46. Smithsonian Institution/John F. Kennedy Center for the Performing Arts

47. Smithsonian Institution/National Gallery of Art

48. Smithsonian Institution/Woodrow Wilson International Center for Scholars

49. Trade and Development Agency 

50. U.S. Holocaust Memorial Museum 

51. U.S. Institute of Peace 

52. U.S. Interagency Council on Homelessness

53. Vietnam Education Foundation 

54. White House Commission on the National Moment of Remembrance
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 65 GAO-08-864R Chemical Safety Board 

49

Attachment 2—Types of NTSB Aviation 

Accident and Incident Investigations

Investigation of occurrences that do not involve fatalities. Investigators Typically no No

do not typically travel for these investigations but instead conduct an

investigation from the office. 

Incident investigation 29 b

Investigations of accidents that do not involve any fatalities, “critical” No No

serious injuries, and other criteria. Investigators do not travel to the 

accident site but instead collect and analyze information from the

office in order to determine the cause.

Data collection 739

accident investigation

Investigation of accidents that can involve a fatality but typically do No Typically no

not. Investigators do not travel to the accident site but instead conduct

a limited investigation using information collected by Federal Aviation

Administration officials, local officials, rescue response units and other

persons, and organizations that may have knowledge of the incident.

Limited investigation 550 a

Investigation of an accident that typically involves a fatality. At least Yes Typically yes

one investigator travels and there is a significant amount of follow-up 

investigation from the office.

Field investigation 196 a

Investigation of a significant accident that typically involves fatalities, Yes Yes

multiple injuries, considerable property damage, or significant public

interest. A team of investigators travels to the accident site.

Major investigation 7

Fatalities

Description Travel involved? involved?

Number in

fiscal year 

Type of investigations 2006

aIncludes investigations of public use aircraft. bThese occurrences do not meet criteria to be defined as an official accident but are still deemed important enough to investigate.
Enclosure II: Slides from April 17, 2008, 

Briefing to Congressional Staff

Page 66 GAO-08-864R Chemical Safety Board 

50

Attachment 3—Types of NTSB Accident 

Reports

Reports that briefly summarize the probable cause of an accident. This type of 

report is issued for all aviation accidents and for all nonmajor railroad, highway,

pipeline, and marine accidents investigated by or for NTSB, for which probable

cause is determined.

Nonmajor accident reports

(or “accident briefs”)

Reports that provide detailed narrative accounts of the facts, conditions, 

circumstances, analysis, conclusions, and probable cause of an accident. This

type of report is issued for major aviation, railroad, highway, pipeline, and marine

accident investigations. 

Major accident reports

Type Description
Enclosure III: Comments from CSB 

Page 67 GAO-08-864R Chemical Safety Board 

Enclosure III: Comments from CSB 

Note: GAO comments 

supplementing those in 

the report text appear at 

the end of this enclosure. 

See comment 1. 

See comment 2. 

See comment 3. 
Enclosure III: Comments from CSB 

See comment 4. 

See comment 5. 

See comment 6. 

See comment 7. 

See comment 8. 

See comment 9. 

See comment 10. 

Page 68 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

See comment 12. 

See comment 11. 

Page 69 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

See comment 13. 

See comment 14. 

See comment 15. 

Page 70 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

See comment 16. 

Page 71 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

See comment 17. 

See comment 18. 

See comment 19. 

See comment 20. 

Page 72 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

See comment 21. 

Page 73 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

The following are GAO’s comments to the U.S. Chemical Safety and 

Hazard Investigation Board’s letter dated August 9, 2008. 

1. We believe this briefing fairly and factually identifies continuing 

problems with CSB’s governance, management, and oversight that 

have continued since we first reported on CSB, in fiscal year 2000.

1

 We 

conducted this performance audit in accordance with generally 

accepted government auditing standards. Those standards require that 

we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objectives. We believe that the

evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. 

GAO Evaluation 

2. While the inspectors general closed these recommendations, their 

decision was often based on CSB’s commitment to take future actions 

and the IG’s reserving the right to reopen recommendations. As stated 

in the briefing, our analysis shows that CSB has not fully responded to 

key recommendations related to (1) investigating more accidents that 

meet statutory requirements triggering CSB’s responsibility to 

investigate, (2) improving the quality of its accident data, (3) resolving 

human capital problems, and (4) ensuring accountability and 

continuity of management. 

3. The 1990 Clean Air Act Amendments establishing CSB contained the 

following mandates: 

• “The Board shall investigate (or cause to be investigated)...any

accidental release resulting in a fatality, serious injury or 

substantial property damage”2

 (emphasis added). 

• “In no event shall the Board forgo an investigation where an 

accidental release causes a fatality or serious injury among the 

general public, or had [sic] the potential to cause substantial 

property damage or a number of deaths or injuries among the 

general public”3

 (emphasis added). 

 1

GAO, Chemical Safety Board: Improved Policies and Additional Oversight Are Needed 

(GAO/RCED-00-192, July 11, 2000). 

2

42 U.S.C. § 7412(r)(6)(C)(i). 

3

42 U.S.C. § 7412(r)(6)(E).

Page 74 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

As noted in our briefing slides, this language clearly identifies the 

accidental releases CSB is required to investigate; investigations are 

required for all accidental releases that result, or have the potential to 

result, in a fatality, serious injury, or substantial property damage. 

4. While CSB reports that it will seek additional investigation resources 

and “will draft a plan for obtaining information on additional chemical 

accidents occurring in the United States, and clearly set forth a riskbased approach to accident selection and investigation,” it does not 

commit to meet CSB’s statutory mandate or commit to investigating 

more than six accidents per year. However, CSB reported that the 

agency would work with Congress to clarify the issue of its statutory 

mandate and, if appropriate, seek an amendment to its authorizing 

statute. 

Also see comment 3. 

5. A more useful benchmark for comparison between CSB and NTSB is 

to examine their appropriations and accident investigations. As noted 

on slide 15, while NTSB’s budget is 8 times CSB’s budget, NTSB 

investigated 250 times as many accidents. In addition, while CSB notes 

that the majority of NTSB’s accident investigations were nonfatal, the 

majority of accidents CSB screened were also nonfatal, as stated on 

slide 14. 

CSB also notes that NTSB relies “heavily on the work of FAA.” CSB 

could similarly rely more on the work of EPA and OSHA and already 

has cooperative agreements in place with these agencies to share 

information on accidents. The agency currently has memorandums of 

understanding (MOU) with both EPA and OSHA with the stated 

purpose of establishing “policy and general procedures for cooperation 

and coordination between the two Agencies to minimize duplication of 

activities.” Moreover, the MOUs state the two agencies will “coordinate 

incident notification, data and information exchange, training, 

technical and professional assistance.” The MOU with EPA further 

states that “in certain instances, the CSB may decide not to send an 

investigation team to the site of a chemical incident. Rather, CSB may 

collect incident information from EPA or other on-site agencies 

compiled in the course of their own actions.” Similar language appears 

in the MOU with OSHA.

6. In our view, this approach would not be consistent with CSB’s own 

authorizing legislation. NTSB’s authorizing legislation gives it broad 

discretion in determining which accidents in the nonaviation 

Page 75 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

transportation modes to investigate. For example, NTSB “shall 

investigate or have investigated...a highway accident, including a 

railroad grade crossing accident, the Board selects in cooperation with 

a State”4

 (emphasis added). In addition, NTSB’s authorizing legislation 

requires investigations of “any other accident related to the

transportation of individuals or property when the Board decides” that 

certain circumstances are present (emphasis added).5

 CSB’s 

authorizing statute, on the other hand, does not contain any similar 

language providing discretion for CSB to determine which accidental 

releases to investigate. 

CSB’s statutory authority is more comparable to the language that 

governs NTSB’s investigations of civil aviation, railroad, and pipeline 

accidents. NTSB is required to investigate railroad accidents with a 

fatality or substantial property, railroad accidents that involve a 

passenger train, and pipeline accidents with fatalities, substantial 

property damage, or significant injury to the environment.6

 Like CSB, 

NTSB is required to investigate these types of accidents; it does not 

have the discretion to choose which to investigate.

Also see comment 3 and 4. 

7. Our recommendation is to develop a plan to address the investigative

gap and request the necessary resources from Congress to meet CSB’s 

statutory mandate or seek an amendment to its statutory mandate. 

Also see comment 3 and 6. 

8. GAO agrees that there are limitations in using the work of others. As 

CSB examines NTSB’s work, it may find that there are lessons to be 

learned about how to minimize the limitations in using the work of 

others. While NTSB uses its authority to solicit the investigative work 

performed by others when resources or other considerations prevent it 

from deploying to accident sites, in all cases, overall investigative 

control—including determination of probable cause—rests with NTSB. 

As we reported in 2007, outside experts provide critical assistance to 

NTSB investigators. During the course of an investigation, NTSB 

 4

49 U.S.C. § 1131(a)(1)(B). 

5

49 U.S.C. § 1131(a)(1)(F). 

6

42 U.S.C. § 1131(a)(1). 

Page 76 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

supplements its investigative staff through the use of “parties” and 

outside contractors when it needs additional support for fact finding or 

technical analysis. “Party” participants include individuals, agencies, 

companies, and associations that can provide technical expertise 

relevant to a specific accident during the fact-finding phase. 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 the airline and aircraft manufacturer, who may face 

liability for dozens of deaths—both entities that are likely working 

with NTSB as parties to the investigation. Despite such challenges, the 

party system appears to be working well; for example, RAND 

Corporation 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. 

In addition, according to NTSB officials, the agency makes a 

distinction between fact gathering and analysis. Parties are permitted 

to gather facts (evidence) for NTSB, but they are not permitted to 

engage in the analysis of that evidence. 

9. As noted above, CSB’s authorizing statute requires investigations of all 

accidental releases that cause, or have the potential to cause, a fatality, 

serious injury, or substantial property damage. CSB’s authorizing 

statute does not specify, that investigations should be limited to those 

accidental releases that are “major.” In addition, CSB’s authorizing 

statute grants CSB discretion to “utilize the expertise and experience 

of other agencies.”7

Also see comment 3. 

10. CSB could use information available from other entities, including 

OSHA and EPA, to conduct its own independent analysis of accidents, 

although in some cases, CSB may need to supplement information 

 7

42 U.S.C. § 7412(r)(6)(D). 

Page 77 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

provided by other entities through follow-up calls, sending 

investigators to the scene of the accident, or other means. 

Also see comment 8. 

11. When CSB examines the work of NTSB, the agency could review how 

NTSB obtains information from other public entities pertaining to 

ongoing investigations. 

Also, see comments 5 and 8. 

12. An examination of NTSB’s work may provide information about how 

NTSB uses its party process to minimize the limitations in using the 

work of others. 

Also see comments 8 and 11. 

13. We recognize that obtaining the views and opinions of CSB’s 

stakeholders could provide valuable information regarding the 

preparation of a reporting regulation. However, the request for 

information does not in itself provide assurance that CSB will follow 

through and issue a regulation as required by CSB’s authorizing 

statute. Specifically, the statute provides that the board 

“shall...establish by regulation requirements binding on persons for 

reporting accidental releases into the ambient air subject to the 

Board’s investigatory jurisdiction.”8

 CSB’s comments concerning the 

need for such a regulation are not relevant because CSB is legally 

required to promulgate a regulation. In addition, we disagree with CSB 

about the regulation’s usefulness. A reporting regulation would allow 

CSB to obtain more accurate, complete information to meet its 

statutory mandate. 

14. As we note in our briefing, information reported by facilities would be 

a better source than CSB’s current practice of relying mostly on 

information from the media, which CSB officials acknowledge is often 

inaccurate or incomplete. Our analysis of CSB’s accident data showed 

that in fiscal year 2007, CSB received 66 percent of its chemical

accident notifications exclusively from the news media. In addition, 

CSB’s accident database is not just for selection of accidents to 

investigate, it is also used to report to Congress and serves as a 

 8

42 U.S.C. § 7412(r)(6)(C)(iii). 

Page 78 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

historical record of information on chemical accidents that could be 

used to identify trends and patterns in chemical accidents and prevent 

future accidents. 

See also comment 13. 

15. The Department of Homeland Security Inspector General (DHS IG) 

reported in 2004 that the lack of comprehensive and timely reporting 

on chemical accidents in general is a problem the CSB is both 

positioned and required to address.9

 Citing a 2002 CSB report on 

reactive hazards,10 the DHS IG reported that “CSB searched 40 public 

and private databases and reported that its findings were limited 

because existing sources of incident data are inadequate to identify the 

number, severity, frequency, and causes of reactive incidents. CSB’s 

analysis included chemical accident data at EPA and OSHA. 

Also see comments 13 and 14. 

16. We introduced the recommendation for reinstating a permanent COO 

as one way CSB could begin addressing the management and 

accountability problems that we have presented in this briefing. As 

stated in the briefing, the difficulties that CSB has experienced in 

meeting its mission are largely the result of inadequate management 

accountability for addressing long-standing problems. If CSB officials 

recognize these long-standing problems and agree that they need to be

addressed, then reinstating a permanent COO could help provide the 

continuity of management needed to bring about this change. In 

addition, former Chairman Carolyn W. Merritt testified in July 2007 

that CSB 

“would benefit...if Congress...provided for a vice chairman to assure the orderly

transition during times when the chair is vacant. Periodic vacancies in the chair, 

and the resulting absence of executive authority, pose a significant risk to the 

success of the agency. Under the existing structure, CSB board members cannot

 9

Department of Homeland Security Office of Inspector General, A Report on the 

Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board, 

OIG-04-04 (Jan. 7, 2004). 

10U.S. Chemical Safety and Hazard Investigation Board, Improving Reactive Hazard

Management, Sept. 17, 2002. 

Page 79 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

serve beyond the expiration of their five-year terms, and thus vacancies in the 

chair and other board seats are all but inevitable.” 11

17. While we recognize that alternatives exist for providing CSB with 

management oversight, after reviewing various oversight options, we 

continue to believe that the EPA IG has several advantages, provides 

the best option for oversight, and the oversight authority should be 

made permanent. The EPA IG has expertise involving the chemical 

management issues that the Board is charged with investigating, has 

gained knowledge of CSB’s operations and activities in providing the 

Board with oversight over the past several years, and, like other IGs, 

has the requisite independence provided by the IG Act of 1978 

necessary for reviewing and making recommendations to address longstanding problems in the Board’s management performance. 

18. We recognize that Congress provided for a division of responsibility 

between the Department of Transportation (DoT) IG and GAO 

regarding the oversight of NTSB. However, GAO has largely devoted 

its efforts to program evaluations and policy analyses that look at 

programs and functions across government and with a longer-term 

perspective. On the other hand, IGs have been on the front line of 

combating fraud, waste, and abuse within their respective agencies, 

and their work has generally concentrated on specific program-related 

issues of immediate concern with more of their resources going into 

uncovering inappropriate activities and expenditures through an 

emphasis on investigations. IGs play a critical role in identifying 

mismanagement of scarce taxpayer dollars and could provide, based 

on the results of our evaluation, a valuable service for the CSB. 

Moreover, as we have stated in the past, we believe that all significant 

federal programs and entities should be subject to oversight by 

independent IGs. 

See comment 17. 

19. In response to CSB’s point that Congress has “consistently and 

specifically rejected” assigning the DoT IG to serve as IG of the NTSB, 

we note that the DoT IG’s assignment to and GAO annual audit 

requirements of the NTSB are recent actions—the DoT IG was 

 11Testimony of Carolyn W. Merritt, Chairman and Chief Executive Officer, U.S. Chemical 

Safety and Hazard Investigation Board before the U.S. Senate Committee on Environment 

and Public Works, Subcommittee on Transportation Safety, Infrastructure Security, and 

Water Quality, July 10, 2007. 

Page 80 GAO-08-864R Chemical Safety Board 
Enclosure III: Comments from CSB 

assigned to NTSB in 2000 and GAO assigned in late 2006. As stated in 

the briefing, we believe that all significant federal programs and 

entities should be subject to oversight by IGs who can provide sound, 

independent audits of all significant federal operations and activities. 

While we recognize that the Congress took specific actions it felt 

appropriate to ensure the independence of NTSB, we note that 

Congress has not taken such action with respect to CSB. Furthermore, 

IGs are independent from the agency they audit and investigate, and

we believe the EPA IG has the requisite independence from CSB. 

See comment 17 and 18.

20. As stated in the briefing, CSB’s history of management problems 

warrants a level of independent oversight that may be difficult to 

achieve by an internal audit function. In addition, the limited staffing 

that would reasonably be allocated to this function at an agency of this 

size would lack the varied expertise needed to address these problems. 

21. As stated in the briefing, we believe that all significant federal

programs and entities should be subject to oversight by IGs who can 

provide sound, independent audits of all significant federal operations 

and activities. Given the management problems that our audit 

revealed, the need for independent IG oversight is especially pressing. 

We also note that these management problems would not be addressed 

by financial or information security audits. 

See comment 17, 19 and 20. 

(360894) Page 81 GAO-08-864R Chemical Safety Board 
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