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67–624 2011

S. HRG. 109–1145 

REAUTHORIZATION OF THE NATIONAL 

TRANSPORTATION SAFETY BOARD (NTSB) 

HEARING 

BEFORE THE

SUBCOMMITTEE ON AVIATION 

OF THE

COMMITTEE ON COMMERCE, 

SCIENCE, AND TRANSPORTATION 

UNITED STATES SENATE 

ONE HUNDRED NINTH CONGRESS 

SECOND SESSION 

MAY 24, 2006 

Printed for the use of the Committee on Commerce, Science, and Transportation 

( 

(II) 

SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION 

ONE HUNDRED NINTH CONGRESS 

SECOND SESSION 

TED STEVENS, Alaska, Chairman 

JOHN McCAIN, Arizona 

CONRAD BURNS, Montana 

TRENT LOTT, Mississippi 

KAY BAILEY HUTCHISON, Texas 

OLYMPIA J. SNOWE, Maine 

GORDON H. SMITH, Oregon 

JOHN ENSIGN, Nevada 

GEORGE ALLEN, Virginia 

JOHN E. SUNUNU, New Hampshire 

JIM DEMINT, South Carolina 

DAVID VITTER, Louisiana 

DANIEL K. INOUYE, Hawaii, Co-Chairman 

JOHN D. ROCKFELLER IV, West Virginia 

JOHN F. KERRY, Massachusetts 

BYRON L. DORGAN, North Dakota 

BARBARA BOXER, California 

BILL NELSON, Florida 

MARIA CANTWELL, Washington 

FRANK R. LAUTENBERG, New Jersey 

E. BENJAMIN NELSON, Nebraska 

MARK PRYOR, Arkansas 

LISA J. SUTHERLAND, Republican Staff Director 

CHRISTINE DRAGER KURTH, Republican Deputy Staff Director 

KENNETH R. NAHIGIAN, Republican Chief Counsel 

MARGARET L. CUMMISKY, Democratic Staff Director and Chief Counsel 

SAMUEL E. WHITEHORN, Democratic Deputy Staff Director and General Counsel 

LILA HARPER HELMS, Democratic Policy Director 

SUBCOMMITTEE ON AVIATION

CONRAD BURNS, Montana, Chairman 

TED STEVENS, Alaska 

JOHN MCCAIN, Arizona 

TRENT LOTT, Mississippi 

KAY BAILEY HUTCHISON, Texas 

OLYMPIA J. SNOWE, Maine 

GORDON H. SMITH, Oregon 

JOHN ENSIGN, Nevada 

GEORGE ALLEN, Virginia 

JOHN E. SUNUNU, New Hampshire 

JIM DEMINT, South Carolina 

JOHN D. ROCKEFELLER IV, West Virginia, 

Ranking 

DANIEL K. INOUYE, Hawaii 

BYRON L. DORGAN, North Dakota 

BARBARA BOXER, California 

MARIA CANTWELL, Washington 

FRANK R. LAUTENBERG, New Jersey 

BILL NELSON, Florida 

E. BENJAMIN NELSON, Nebraska 

MARK PRYOR, Arkansas 

(III) 

C O N T E N T S 

Page 

Hearing held on May 24, 2006 ............................................................................... 1 

Statement of Senator Burns ................................................................................... 1 

Statement of Senator Lautenberg .......................................................................... 9 

WITNESSES

Dillingham, Gerald L., Ph.D., Director, Physical Infrastructure Issues, United 

States Government Accountability Office (GAO) ............................................... 10 

Prepared statement .......................................................................................... 12 

Rosenker, Hon. Mark V., Acting Chairman, National Transportation Safety 

Board, NTSB ........................................................................................................ 2 

Prepared statement .......................................................................................... 4 

APPENDIX

Response to written questions submitted by Hon. Daniel K. Inouye to Gerald 

L. Dillingham ....................................................................................................... 41 

(1) 

REAUTHORIZATION OF THE NATIONAL 

TRANSPORTATION SAFETY BOARD (NTSB) 

WEDNESDAY, MAY 24, 2006 

U.S. SENATE, SUBCOMMITTEE ON AVIATION, COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION, Washington, DC. 

The Committee met, pursuant to notice, at 8:55 a.m. in room 

SD–562, Dirksen Senate Office Building, Hon. Conrad Burns, 

Chairman of the Subcommittee, presiding. 

OPENING STATEMENT OF HON. CONRAD BURNS, 

U.S. SENATOR FROM MONTANA 

Senator BURNS. We’ll call the Committee to order. I assume that 

I’ll have some colleagues come by. Looks like we’re going to have 

a 9:30 vote, of all things, and, you know, Senators don’t even wake 

up until about 11:30, so there may be lots of votes changing. You 

know, the brain doesn’t wake up until about noon and mine has 

the problem of, ‘‘you think you’re early don’t you?’’ 

[Laughter]. 

Senator BURNS. But, I thought we’d get started, and I think Senator Lautenberg and Senator Snowe will be here later on. I appreciate the witnesses coming at 9 a.m. this morning, I realize it’s a 

little early for the hill to start, but not for you. You folks are already at work, we don’t have to call you up. But nonetheless, you 

do have to call the rest of us. Although, if I had my druthers, I’m 

a farm broadcaster and worked around the stockyards all my life 

and any time after, any time, if you haven’t got your work done by 

8:30 or 9 a.m. in the morning, you’re just doing nothing but burning daylight, and so we like to get up and get around. 

I’ll just have a short statement this morning, and I appreciate 

the early hour of you all coming. Today, we review the authorization, or the reauthorization of the National Transportation Safety 

Board. It’s an independent agency determining the probable cause 

of transportation accidents and promoting transportation safety. 

The Agency has played a key role throughout the years in improving the safety of the traveling public across all modes and across 

this land. 

Since the 1960s, the NTSB has investigated more than 124,000 

aviation accidents, at least 10,000 accidents in other transportation 

modes, including rail, pipeline, maritime, and highways. Through 

those investigations, the Board has issued 12,000 safety recommendations, and more than 82 percent of those have been adopted by the regulatory and transportation communities. 

2 

The Board reauthorization runs out on October 1 of this year. 

That’s the reason that we’re moving ahead to make sure that it 

gets done, and, therefore, in coordination with Senator Lott, and 

the members of the Surface Transportation Subcommittee, we will 

soon produce a NTSB Reauthorization bill. So, I am hopeful that 

we can move that bill through Congress and complete our work by 

the October deadline. I look forward in working with all my CoChairmen on this committee to get it out. 

I believe a timely review of the NTSB is important. The Committee is confident that proper management practices are in place 

at the Agency, and effective use of taxpayer dollars are ensured. 

The Committee has had questions regarding accident investigator 

staffing levels, usage of NTSB Academy, and the timeliness and 

process of investigations, and we appreciate Dr. Dillingham being 

here this morning and the work that he has done on this. I don’t 

know if anybody in this town knows more about the NTSB than 

Dr. Dillingham. I will tell you that every Committee that we’ve 

ever talked about, well he has always been a part of that, and I 

appreciate your work and your institutional knowledge is terrific. 

With that, I appreciate our witnesses coming early this morning 

as we get into this business of reauthorization. 

And, first off, we want to welcome Mark Rosenker, the Acting 

Chairman of the NTSB to the table this morning and thank you 

for coming, and thank you for the visit in my office and we appreciate your energy and your efforts with regard to this vital part of 

government. Thank you for coming, looking forward to your statement. 

STATEMENT OF HON. MARK V. ROSENKER, ACTING 

CHAIRMAN, NATIONAL TRANSPORTATION SAFETY BOARD 

Mr. ROSENKER. Thank you, Mr. Chairman. Good morning. As 

Acting Chairman of the National Transportation Safety Board, I’m 

pleased to appear before you today in support of our request for reauthorization. I’ve submitted a more comprehensive statement for 

the record. 

Senator BURNS. Well I, let me say that there’ll probably be some 

questions coming because we’ve only got this half hour and your 

full statement will be made part of the record, and then any questions will come after we close this session this morning. You can 

respond to the Committee and to the individual Senator if you 

would please. 

Mr. ROSENKER. I’d be delighted to do that, sir. 

Senator BURNS. Thank you. 

Mr. ROSENKER. I’m very proud of the National Transportation 

Safety Board. For nearly four decades the NTSB has been at the 

forefront of transportation safety issues. The Board enjoys a well 

earned reputation as the most effective and authoritative independent safety body in the world. The men and women who make 

up the NTSB, very simply, are the best in the business. I am privileged to be serving as Acting Chairman, and particularly honored 

that President Bush has recently sent my nomination to be Chairman of the NTSB to the full Committee for your consideration. 

Our critical mission is to investigate transportation accidents, to 

determine what happened, and why, and make recommendations 

3 

so that future accidents can be prevented. My job is to ensure that 

the Board maintains the technical staff and investigative tools that 

are needed to confidently and efficiently conduct the thorough and 

unbiased investigations that the public deserves and the Congress 

has come to expect. 

Since our last reauthorization, the Board has investigated more 

than 4,500 aviation accidents and hundreds of surface transportation accidents. During this time, we published more than 5,000 

aviation accident briefs, 12 major aviation accident reports, 19 

highway accident reports, 31 railroad reports, 10 marine reports, 5 

pipeline reports, 4 hazardous material reports and 7 other studies 

in special reports. 

Since the beginning of this fiscal year, excuse me, since Fiscal 

Year 2003, our laboratories have read out 187 flight data recorders, 

203 cockpit voice recorders, and performed 458 wreckage examinations. During this time, the Board has issued more than 450 safety 

recommendations. 

We’ve also made some significant leadership changes at the 

Board. In March 2005, Joe Osterman was appointed our new Managing Director with new senior leadership and the support of our 

Board Members, the NTSB has reinvigorated its focus on the completion of investigations and the production of accident reports. 

During the past year, the Board has changed personnel in 14 of 

the top 24 leadership positions, and we are currently actively recruiting a Chief Information Officer, who will join the agency’s 

management team with the responsibility of managing the agency’s 

information infrastructure. We are tightening the performance 

management system throughout the agency and have focused our 

efforts on leadership, communication, and the Board’s core mission. 

The Safety Board is asking for authorized resource levels capable 

of funding 399 full-time equivalent positions in Fiscal Year 2007, 

and 475 FTEs in both Fiscal Years 2008 and 2009. We also have 

a few other proposals. The Board’s last reauthorization legislation 

provided the authority for the NTSB to enter into contract, without 

competition when necessary, to expedite an investigation. 

We are grateful to have been entrusted with this special exemption to competitive contracting rules. We have judiciously used this 

authority—mostly for relatively small contracts for investigative 

services. This important authority expires September 30 in 2006 

and we are asking that this sunset provision be deleted so the special contracting authority becomes a permanent part of our legislation. 

The Board also asks to be authorized to handle reimbursements 

in the same manner it currently handles Academy course fees. Occasionally, we are reimbursed by third parties for accident services 

for those parties who are required to provide, such as disaster mortuary services, and we sometimes agree to conduct accident investigations on a reimbursable basis. Without legislative change, these 

reimbursements often must be re-deposited into the Treasury, unavailable for use by the Board. We are asking that we be allowed 

to treat reimbursement as ‘‘no year’’ money, so that these funds remain available until expended. 

The Board has a proposal that concerns the paying of services for 

the DOT Inspector General. As you know, the Inspector General is 

4 

authorized to review the financial management, property management, and business operations of the Board. The IG is reimbursed 

by the Board for the costs associated in carrying out these activities. We are asking that, in lieu of the Board reimbursing the IG, 

the IG’s Office should be appropriated directly for these activities. 

This would facilitate better resource management, and I am 

pleased to report that the DOT Inspector General concurs with this 

proposal. 

Our last proposal concerns how to authorize appropriations for 

our training center, as part of the broader authorization for the 

agency. Rather than as a separate or distinct entity, we’re actively 

working to more fully integrate the center into our overall mission 

and programs, and we believe that a single authorization is consistent with this goal. In addition, we propose incorporating the 

content of the Training Academy’s annual report into the Board’s 

annual report to Congress. 

When we were last reauthorized, our Training Academy in 

Ashburn, Virginia, was not yet open. Although it has been operational for just two years, we are pleased that the Academy has 

made great strides in developing and delivering high quality programs for the transportation community. During Fiscal Year 2005, 

we offered 31 programs, 14 of which were designed specifically for 

NTSB employees. Over 1,600 participants attended these programs 

and the Board collected almost a half a million dollars from tuitions and fees from the attendees. 

Nonetheless, the Safety Board senior management has significantly revised the philosophy for the Academy, and has created a 

plan to develop and sustain programs through partnerships and 

contracting opportunities that will reduce the demands on NTSB 

investigative resources. The Academy will rely more heavily on outside instructors, and it will provide greater training opportunities 

for all NTSB staff. 

We will also work with and review the operations of other government facilities to ensure that we benefit from their experiences 

and best practices. One of our goals is to more tightly integrate the 

Academy into the Safety Board’s operation and ongoing work. 

As I close, I want to assure you that we are working hard to 

guarantee the American people that the resources of the Board are 

well managed. In fact, I am proud to tell you that in each of the 

last three fiscal years, our timely and accurate financial statements 

have received clean audit opinions. Important things are happening 

at the Safety Board every day, but we need the continued support 

of Congress to ensure we continue to achieve our goals. I thank 

you, Mr. Chairman, for the opportunity to appear before you today, 

and I’m happy to respond to any questions you or the Committee 

may have. 

[The prepared statement of Mr. Rosenker follows:] 

PREPARED STATEMENT OF HON. MARK V. ROSENKER, ACTING CHAIRMAN, 

NATIONAL TRANSPORTATION SAFETY BOARD

Good morning, Chairman Burns, Ranking Member Rockefeller, and members of 

the Aviation Subcommittee. As Acting Chairman of the National Transportation 

Safety Board, I am pleased to appear before you today in support of our request for 

reauthorization. I am delighted to be serving as Acting Chairman of the NTSB at 

such an important time at the Board. As you know, the Safety Board has a critical 

5 

mission: We investigate transportation accidents to determine what happened and 

why—not so that we can assign blame or determine fault. Rather, we do this work 

so that future accidents can be prevented. The core mission of the Safety Board has 

remained the same since the Board’s inception in 1967. We are, however, reframing 

our efforts and activities on that core mission, by examining all of our programs and 

activities to ensure that we are diligently focused on conducting accident investigations and issuing safety recommendations. Transportation accidents are increasingly 

complex, and the tools and technology available for accident investigation are also 

increasing in sophistication. However, we intend to ensure that despite these 

changes, our emphasis remains on quality investigations and timely safety recommendations that prevent transportation accidents, and reduce the deaths and injuries resulting from accidents that do occur. Our job is to work with you to ensure 

that the Board maintains the technical staff and investigative tools that are needed 

to confidently and efficiently conduct the thorough and unbiased investigations that 

the public deserves. 

Safety Board Activity 

Let me give you a brief overview of what the Board has accomplished since our 

last reauthorization. Since the beginning of Fiscal Year 2003, the NTSB has held 

6 public hearings and 47 Board meetings. We adopted 56 reports at those Board 

meetings. We also investigated more than 4,500 aviation accidents, and hundreds 

of surface transportation accidents. During this time, we published more than 5,000 

aviation accident brief reports, 11 major aviation accident reports, 19 highway accident reports, 32 railroad reports, 11 marine reports, 5 pipeline reports, 4 hazardous 

materials reports, and 8 other studies and special reports. Since the beginning of 

Fiscal Year 2003, our laboratories read out 187 flight data recorders, 203 cockpit 

voice recorders, and performed 458 wreckage examinations. During this time period, 

the Board issued more than 450 safety recommendations (about 45 percent pertain 

to aviation, and the remaining recommendations pertain to surface transportation). 

Already, 67 (about 15 percent) of these recommendations have been successfully implemented. 

On March 7, the Board held a meeting to consider two accident investigation reports: the capsizing of a water taxi in Baltimore, Maryland, and the crash of a Sikorsky S–76 helicopter in the Gulf of Mexico, about 70 nautical miles from Galveston, Texas. Five of the 23 water taxi occupants were killed, and all 10 of those 

aboard the helicopter died in that accident. 

Some of the other investigations that we concluded since our last reauthorization 

include: 

• The January 6, 2005, collision of two Norfolk Southern trains in Graniteville, 

South Carolina,which resulted in the release of chlorine gas from a breached 

tank car, and killed 9 people. 

• The November 28, 2004, crash of a Canadair Challenger airplane during takeoff 

from Montrose Regional Airport, Colorado. There were 6 persons aboard, 3 of 

whom were killed. Among the passengers were NBC television executive Dick 

Ebersol and members of his family. 

• The October 24, 2004, crash of the Beech King Air that was transporting employees of Hendrick Motorsports. The airplane crashed while attempting to land 

at Martinsville, Virginia. All 10 persons aboard the airplane died. 

• The October 19, 2004, crash of Corporate Airlines Flight 5966, a British Aerospace ‘‘Jetstream’’ that crashed short of the runway while attempting to land 

at Kirksville Regional Airport, Missouri. The 2 pilots and 11 of the 13 passengers were killed. 

• The October 15, 2003, accident involving the Ferry Andrew J. Barberi, which 

struck a maintenance pier at the Staten Island Ferry terminal. Eleven passengers died and 70 were injured. 

• The October 12, 2003, Chicago, Illinois, Metra commuter derailment that resulted in 3 injuries and more than $5,000,000 dollars in damage. 

• The October 1, 2003, tractor-trailer collision with a specialty bus that killed 8 

elderly passengers in Hampshire, Illinois. 

• The February 14, 2003, accident in which a motorcoach crossed a highway median in a rainstorm striking an SUV and killing 7 in Hewitt, Texas. 

• The Beechcraft King Air that crashed near Eveleth, Minnesota, on October 25, 

2002, killing all 8 people aboard, including Sen. Paul Wellstone. 

• The May 26, 2002, accident that resulted when the towboat Robert Y. Love 

rammed a pier supporting the Interstate 40 bridge over the Arkansas River 

6 

near Webbers Falls, Oklahoma. The impact collapsed a 503-foot section of the 

bridge, which fell into the river and onto the barges below. The accident resulted in 14 fatalities and 5 injuries. 

• The November 12, 2001, crash of American Airlines flight 587, an Airbus A300, 

which crashed into a Queens, New York, neighborhood shortly after taking off 

from John F. Kennedy International Airport. All 260 people aboard the plane 

died, as did 5 persons on the ground. This is the second deadliest aviation accident in American history. 

The Board also issues special reports and studies. For example, since we were last 

reauthorized, we issued a safety report on the Rollover Propensity of 15-Passenger 

Vans. Also, we issued a special report on medical oversight of noncommercial drivers. Late last year, we published a study on liquid pipeline control and data acquisition systems, and we also published a study on general aviation flights in bad 

weather. In January of this year, the Board issued a special report on emergency 

medical services (EMS) flights that resulted in a number of safety recommendations 

to the FAA. We undertook the special report after investigating fifty-five EMS accidents over the three-year span between January 2002 and January 2005. 

We also have a number of important accident investigations in progress. These 

include: 

• The February 8, 2006, fire involving a UPS DC–8 cargo airplane at Philadelphia 

International Airport. 

• The December 19, 2005, Chalk’s Airlines passenger seaplane accident in Miami, 

Florida, that killed all 20 on board. 

• The December 13, 2005, natural gas explosion in Bergenfield, New Jersey that 

killed 3. 

• The December 8, 2005, Southwest Airlines runway overrun at Chicago’s Midway airport that killed a six-year-old boy who was an automobile passenger. 

• The October 2, 2005, tour boat Ethan Allen capsizing in Lake George, New 

York, which resulted in 20 deaths. 

• The September 23, 2005, bus fire near Wilmer, Texas, that killed 23 people who 

were being evacuated due to Hurricane Rita. 

• The February 16, 2005, accident in Pueblo, Colorado, involving a Circuit City 

Cessna Citation 560 corporate jet. The 2 pilots and 6 passengers were killed in 

the crash. 

• The February 2, 2005, accident involving a Canadair CL–600 corporate jet, at 

Teterboro Airport in New Jersey. The airplane overran the runway during an 

aborted take-off resulting in 4 seriously injured persons. 

In addition to domestic accidents, the Board often sends investigators to other 

countries to investigate aviation accidents, and I want to highlight this important 

responsibility. When a U.S.-manufactured, U.S.-registered, or a U.S.-operated aircraft is involved in an accident overseas, the Safety Board leads the U.S. participation in the investigation. Each year, our investigators participate in about 20 major 

foreign aviation accidents. For example, in August of last year, the Board sent a 

team to participate in the investigation of a Sikorsky S–76 helicopter that crashed 

into the Baltic Sea off the coast of Estonia. Also last year, the Board sent investigators to participate in the investigation of an Airbus A340 runway overrun in Toronto, and Boeing 737 crashes in Indonesia, Nigeria, and Greece. Also, last summer, 

the State Department asked the Board to send a team to assist in the investigation 

of the crash of a Russian-built M–172 helicopter near the Sudan/Uganda border. 

The crash killed 14 people, including Sudan’s First Vice President John Garang. 

Our involvement in this investigation has helped allay fears among the Sudanese 

people that the aircraft was brought down by a criminal act. Our foreign work is 

vitally important to aviation safety because some countries may lack the technology 

and expertise that we possess, and it protects U.S. interests by ensuring that a 

proper and fair investigation results when American-built and American-registered 

aircraft are involved in accidents in other countries. Also, because many of the accidents that happen in other countries could have happened here, our participation 

in these investigations results in major safety improvements for the domestic fleet. 

Each investigation is important, but our goal is preventing future accidents, saving lives, and reducing injuries. That is why we often say that safety recommendations are our most important products. Each year, the Board meets to determine 

which of its open recommendations should appear on its list of Most Wanted transportation safety improvements. Our 2006 Most Wanted list includes several aviation 

safety recommendations to the Federal Aviation Administration (FAA), urging them 

7 

to reduce the dangers of in-flight icing, eliminate flammable vapors in transport category airplane fuel tanks, prevent runway incursions, require restraints for children 

under age two, and to improve the crashworthiness of recorders. The most important safety improvement needed for our country’s railroads is positive train control. 

If the Federal Railroad Administration (FRA) required positive train control systems, it would prevent collisions and overspeed accidents. The Most Wanted safety 

improvements for the highway mode include improving motor carrier safety, preventing medically unqualified drivers from operating commercial vehicles, and enhancing the protection of bus passengers. The list also includes recommendations 

to the Department of Transportation (DOT) modal administrations to update the 

hours of service rules for transportation workers. In addition, our Most Wanted list 

includes recommendations to the states to enact laws that promote seatbelt usage, 

ensure child occupant protection, improve youth highway safety, and to eliminate 

hard-core drinking and driving. The list also includes recommendations to improve 

school bus safety and make grade crossings and recreational boating safer. 

Although open safety recommendations are important, standing alone they do not 

represent safety improvements. The results that we need are the actions of industry 

and government representatives to improve safety by implementing the Board’s recommendations. When the recipients of the Board’s recommendations respond, we 

carefully consider the actions taken, and, if appropriate, close the recommendations 

by majority vote of the Board Members. 

When we appeared before you during our last reauthorization cycle in 2002, the 

Board had more than 1,100 open safety recommendations, and that many had been 

open for several years. About half of the open recommendations were to the DOT 

and its modal administrations. We have been working with all of the modal administrations to implement the recommended safety actions, and to close the old recommendations. I am pleased to report that our safety recommendation acceptance 

rate is over 82 percent, and in 2005, the Board reduced the number of open safety 

recommendations to 810, the lowest number since 1971. We are proud of these numbers, but remain committed to holding our ground on each recommendation, ensuring that the most sensible safety actions are implemented. 

Another issue that we pointed out to you when we last came forward for reauthorization was the state of relations between the Safety Board and the Coast Guard. 

At that time we had been working on a Memorandum of Understanding (MOU) for 

six years without being able to come to an agreement on investigating marine accidents. There was a need for a closer and more productive working relationship. I 

am pleased to tell you that the memorandum was finalized and signed in September 

2002, and the MOU is working quite well. More importantly, our relations with the 

Coast Guard have improved tremendously in the last few years, and we look forward to continued partnership in the years to come. 

When we were last reauthorized, our Academy in Ashburn, Virginia, had not yet 

opened. In September 2003, the Academy staff took up occupancy in the new building, which has 5 classrooms, office space, a large laboratory to house the TWA flight 

800 reconstruction, and other laboratory spaces and meeting rooms. The facility is 

also home to one of our aviation regional offices. Finally, it also serves as the 

Board’s continuity of operations (COOP) site, and as a backup COOP site for two 

other Federal agencies. 

A part of the Academy’s mission is to provide training on transportation safety 

and accident investigation. Since the Academy became operational, its staff has focused primarily on improving and expanding existing programs. In response to Congressional concerns about the use of investigative resources to support Academy 

courses, in 2006, Safety Board management significantly revised the philosophy for 

the Academy. We will focus upon developing and sustaining innovative and stateof-the-art training courses and programs. The Board will explore partnership and 

contracting possibilities that will yield higher returns, with decreased demands on 

NTSB investigative resources by relying more heavily on instructors from academia, 

government, and the private sector. This will also provide greater training opportunities for all NTSB staff. We also plan to establish a Training and Academic Oversight Board composed of senior NTSB staff. The Oversight Board will oversee the 

curriculum developed by contractors and other third parties. We will also work with 

and review the operations of other government training facilities to ensure that we 

benefit from their experience and best practices. One of our goals is to more tightly 

integrate the Academy into the Safety Board’s operation and ongoing work. To reflect this change in emphasis, we are considering changing the name of the facility 

to the NTSB Training Center. 

Although it has been operational for just over two years, we are pleased that the 

Academy has made great strides in developing and delivering high quality programs 

that are highly relevant to the transportation community. During Fiscal Year 2005, 

8 

we offered 31 programs, 14 of which were designed primarily for NTSB employees. 

Over 1,600 participants attended these programs, and the Board collected almost 

half a million dollars from tuitions and fees from the attendees, which included representatives from organizations like National Aeronautics and Space Administration’s Engineering and Safety Center, Federal Bureau of Investigation’s Evidence 

Response Team, and the Civil Aviation Administration of China. This new strategic 

and management vision will position the training center to move forward and to better serve the needs of the Board and its staff. 

I want to take a moment to assure you of our continued commitment to investigating general aviation accidents. There has been some concern that we are not 

investigating as many general aviation accidents as we should. But I want you to 

know that we lead an investigation into every one of the nearly 1,800 general aviation accidents that occur each year; however, our regional aviation investigators 

cannot travel to every accident site so we rely on some of the FAA’s 3,500 inspectors 

to assist us. We ask these trained aviation inspectors to document the on-site findings and to collect evidence for us. Whether we travel to the accident scene or not, 

we still conduct the research, necessary interviews, and follow-up examinations required for an appropriate investigation. For each case, we write the report and determine probable cause. That is our mandate and we carry it out. 

Reauthorization Request 

The Safety Board is asking for authorized resource levels capable of funding 399 

full-time equivalent (FTE) positions in Fiscal Year 2007, and 475 FTEs in both Fiscal Years 2008 and 2009. The necessary resource levels for Fiscal Years 2007–2009 

are $79.594 million, $99.974 million, and $104.844 million, respectively. 

We began Fiscal Year 2006 with the equivalent of 416 full-time employees on 

board. This is more than our Fiscal Year 2006 budget can support, so we have been 

allowing attrition to shrink this number to a sustainable level. We currently have 

396 FTE on board, and we can sustain this number with our current budget. In the 

last two months, we have initiated some very important human capital planning to 

help us better prepare the NTSB for the future. Our planning indicates that to carry 

out the mission of the Board, we need 475 full-time staff; consequently, this is the 

number that we have proposed for Fiscal Years 2008 and 2009. We recognize that 

this represents growth, but this staffing level is needed to allow us to investigate 

accidents appropriately and issue timely and effective safety recommendations. 

Our reauthorization request also contains several proposals for specific legislative 

language that would improve the Board’s operation. 

The Board’s last reauthorization legislation provided the authority for the NTSB 

to enter into contracts without competition when necessary to expedite an investigation. We are grateful to have been entrusted with this special exemption to competitive contracting rules, and we have judiciously used this authority, mostly for relatively small contracts for investigative services. For example, we have used the authority to contract for non-destructive imaging of aircraft components, as well as for 

marine vessel stability calculations. It can also be used to retrieve important—perhaps perishable—evidence while it is still available. This important authority expires on September 30, 2006, and we are asking that the sunset provision be deleted 

so that the special contracting authority becomes a permanent part of our legislation. 

The Board also proposes that you authorize appropriations for our training center 

as part of the broader authorization for the agency, rather than as a distinct entity. 

As I mentioned, we are actively working to more fully integrate the center into our 

overall mission and programs, and we believe that a single authorization is consistent with this goal. Also, we propose incorporating the content of the training 

academy annual report into the Board’s annual report to Congress. 

The Board also asks to be authorized to credit all reimbursements as offsetting 

collections that would remain available until expended (this authority already exists 

for training center course fees). This would help us better manage our funds when 

we are reimbursed by third parties for accident services that those parties are required to provide. For example, airlines are required to fund disaster mortuary services when these services are needed at crash sites. To ensure the immediate delivery 

of these important services, the Board may commit its own funds immediately after 

an accident, and seek reimbursement later when there is time to sort out the financial responsibility. Also, we occasionally agree to conduct accident investigations on 

a reimbursable basis. For example, the Department of State is reimbursing us for 

conducting the investigation into the helicopter accident that killed the First Vice 

President of Sudan. Without a legislative change, these reimbursements may have 

to be redeposited into the treasury account, unavailable for use by the Board. We 

need the authority to carry forward reimbursements like these. 

9 

Our last proposal concerns paying for the services of the DOT Inspector General 

(IG). As you know, the IG is authorized to review the financial management, property management, and business operations of the Board. The IG is reimbursed by 

the Board for the costs associated with carrying out these activities. Instead of the 

Board reimbursing the IG, we are asking that the IG’s office be appropriated directly for its activities. This would facilitate better resource management, and I am 

pleased to report that the DOT IG concurs with our proposal. 

As I close, I want to assure you that we are working hard to ensure that the people and resources of the Board are well managed. In fact, I am proud to tell you 

that in each of the last three fiscal years, our timely and accurate financial statements have received clean audit opinions from the DOT IG. 

There have been significant leadership changes at the Board recently. In March 

2005, Joe Osterman began serving as the Board’s Managing Director, its highestranking career leader. Mr. Osterman is effectively leading a highly talented management team, and as I mentioned previously, under his leadership, the Safety 

Board has reinvigorated its focus on the completion of investigations and the production of accident reports. 

In fact, over the past year, the Board has changed personnel in 14 of the top 24 

leadership positions. These positions have been filled by highly qualified and experienced professionals from both within and outside the Board. Some noteworthy new 

members of the team are Jack Spencer, the Director of our Office of Marine Safety, 

and Gary Halbert, our General Counsel. Dr. Spencer—an MIT-educated naval architect—comes to us from the private sector, and Mr. Halbert—an accomplished attorney—recently retired from the U.S. Air Force. Both have hit the ground running, 

and are already making important contributions to the Board. Also we are currently 

recruiting for a Chief Information Officer who will join the agency’s management 

team with the responsibility of managing the agency’s information infrastructure. 

We are improving our performance management system throughout the agency, and 

we have refocused our efforts on leadership, communication, and the Board’s mission. 

As I said at the beginning of my testimony, there are important things happening 

at the Safety Board every day. But we need the support of Congress to ensure that 

we have the resources needed to accomplish our mission. I thank you for the opportunity to appear before you today, and I am happy to respond to any questions you 

may have. 

Senator BURNS. Thank you very much. We have been joined by 

my friend and colleague from New Jersey. Senator Lautenberg do 

you have a statement? We’ve only got about a half hour, I guess 

we’re going to have 9:30 votes, is that your understanding? 

Senator LAUTENBERG. That is my understanding also that there 

is a residual, Mr. Chairman—— 

Senator BURNS. Turn your microphone on, would you please, so 

people can hear your docile tones. 

STATEMENT OF HON. FRANK R. LAUTENBERG, 

U.S. SENATOR FROM NEW JERSEY 

Senator LAUTENBERG. That’s from being with my wife, she said 

don’t talk so loud. 

In any event, Mr. Chairman, thanks for calling this hearing, and 

I apologize for the interruption between the sequence here. Thanks 

for calling this hearing and as usual, you’ve focused on matters of 

safety and transportation, and this is an excellent way for us to 

begin a review. The National Transportation Safety Board is a critical, critical factor in our functioning. Transportation has always 

been one of my top priorities in the Senate. A good transportation 

system is critical to our economy and our quality of life, and in the 

State of New Jersey, the most densely populated state in the 

Union, we desperately need to make sure that we’re operating safely and the NTSB is one of the ways to ensure that. 

10 

One absolute requirement beyond safety, is the fact that beyond 

the direct response of an accident is to give us the knowledge and 

the experience to go on to further legislative redress, or rule 

changes, to make the operation of our aviation system and our 

transportation systems more efficient. Most visible of part of the 

NTSB’s job is to investigate actions like airplane disasters. The 

Stanton Island ferry, for instance, is a couple of years ago, or accidents on transit systems. 

We rely heavily on the NTSB to help us learn from these extraordinary accidents, so we can avoid repeating them. But, we must 

also look to the NTSB to help make our highways safer through 

such measures as reducing drunk driving. NTSB recommendations 

provide the basis for change in our laws that protect the traveling 

public, and for example, I’ve introduced a bill to change the way 

we deal with high-risk drunk drivers, based primarily on NTSB research. We’ve made a lot of head way in fighting drunk drivers 

over the last 20 years, and we’ve saved a lot of lives. 

For example, in 1984, I was able to pass a bill that led states 

to increase the drinking age, and that measure has saved more 

than 20,000 lives, and you know, Mr. Chairman, I get asked frequently about, well if someone can go to fight, why can’t they buy 

a drink and so forth and my response is that, if they’ve gone to 

fight, or they’re traveling here in our country, we don’t want to 

make their risks for survival any greater than they would be. And, 

so while it raised a challenge, it saves lives as well. I wholeheartedly support the mission of the NTSB. Like all government 

agencies, the NTSB should be efficient, and in order to do that it 

has to have sufficient resources to have the strength to pursue its 

mission to better protect the traveling public and make our transportation system as safe as possible. 

And, Mr. Chairman, this is a good review and a good time to look 

at it and make sure that we’re poised to provide the kind of funding and the kind of interest that NTSB needs to do its job 

well.Thank you. 

Senator BURNS. Thank you, Senator Lautenberg. Now, Dr. 

Dillingham, thank you for coming this morning, and I look forward 

to your testimony. 

STATEMENT OF GERALD L. DILLINGHAM, PH.D., DIRECTOR, 

PHYSICAL INFRASTRUCTURE ISSUES, UNITED STATES 

GOVERNMENT ACCOUNTABILITY OFFICE (GAO) 

Dr. DILLINGHAM. Thank you, Chairman Burns, Senator Lautenberg. Several months ago, you requested GAO to undertake a comprehensive review of the NTSB. That review is ongoing, but we’re 

pleased to be here today to discuss the findings and recommendations that we’ve developed to date. 

First, GAO agrees with Mr. Rosenker that NTSB has achieved 

a worldwide reputation as a preeminent agency in transportation 

accident investigations. Our research to date has found nothing 

that would have an immediate material affect on that reputation. 

My testimony today addresses the extent to which NTSB is making 

progress in three areas: 

First, following leading practices in selected management areas; 

second, addressing challenges in completing accident investigations 

11 

and closing safety recommendations; and third, utilizing the Academy and generating sufficient revenues to cover its costs. 

With regard to management practices, we found that NTSB has 

recently made progress in this area, but it is very much a work in 

progress. For example, NTSB has begun to develop a strategic plan 

and a performance management system. However, the performance 

management system will not be fully functional until the strategic 

plan has results, oriented objectives and specific strategies for 

achieving them. 

Another example of work in progress is in the area of human 

capital management. NTSB has recently developed a draft staffing 

plan that addresses the agency skills and competency needs, and 

includes strategies for increasing the number of investigators. However, that draft plan does not consider the agency’s organizational 

structure and its balance of supervisory and nonsupervisory positions. 

To its credit, NTSB has improved its financial management by 

hiring a Chief Financial Officer, and putting controls on its purchasing activites, which should address past problems with unapproved purchases on government credit cards. However, NTSB still 

lacks a full cost accounting system which would inform managers 

of the resources spent on individual investigations, and provide 

data to balance office workload. 

With regard to completing accident investigations and closing 

safety recommendations, in the case of major aviation accidents, a 

variety of circumstances contribute to many investigations taking 

longer than two years to complete. The average time it takes NTSB 

to complete this kind of accident investigation increased from one 

and a quarter years in 1996, to three and a half years in 2006. 

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

transportation accidents and 82 percent of its recommendations 

have been implemented or acceptable progress towards implementation has been made. 

However, the implementation of NTSB’s recommendations can be 

a time-consuming process, which can work against the goal of 

quickly improving transportation safety. For example, Federal 

agencies can take years to develop regulations to implement 

NTSB’s recommendations. Additionally, industry also requires time 

to comply with those recommendations. We found that over 300 

NTSB recommendations have been open for five years or more. Mr. 

Chairman, one extreme example of that is the crash of TWA Flight 

800 off of Long Island in 1996. Ten years after the crash, the final 

regulation that addresses the cause of the crash has not been 

issued. 

Additionally, the process that NTSB uses to change the status of 

safety recommendations is paper-based, labor intensive and relies 

on many sequential reviews that can take months to complete. As 

a result, NTSB’s scarce resources are tied up, and agencies don’t 

know whether the responses are accepted or not accepted. 

With regard to the extent to which NTSB is utilizing the Academy and generating sufficient revenues to cover its costs, we found 

that during the last fiscal year, 90 percent of the available classroom space at the Academy was not used. In FY 2006, NTSB employees are scheduled to take 97 percent of their requested training 

12 

from sources outside of the Academy, which translates into over 

$900,000 in costs to NTSB. 

In terms of generating revenues, we found that for Fiscal Years 

2004 and 2005 NTSB’s Academy did not generate sufficient revenues to cover the direct cost of operating and maintaining the 

Academy. As a result, those portions of the Academy’s cost that 

were not covered by the revenues from tuition and other sources, 

approximately $6.3 million in FY 2004, and $3.9 million in 2005, 

had to be offset by general appropriations to the agency. To its 

credit, NTSB has taken some action to generate revenues from 

other sources such as renting Academy space for conferences. However, these actions have not been sufficient to close the gap, nor are 

they likely to do so without a comprehensive marketing plan. 

Chairman Burns, Senator Lautenberg, our written statement 

recognizes NTSB’s recent efforts in each of these areas that we’ve 

discussed, and makes recommendations to the Chairman of the 

Board. To improve the management practices, we recommended 

that NTSB develop a revised strategic plan that has results oriented objectives and specific strategies for achieving them. 

We also believe that the development of a full cost accounting 

system is a critical need for resource management. To enhance the 

efficiency of the report development and recommendation close-out 

processes, we recommend that the Chairman identify effective 

practices from throughout NTSB and apply them to all modes. 

And to enhance the utilization of the Academy and improve the 

ability to generate revenues, we recommend that the Chairman develop a comprehensive marketing plan. The plan should consider 

the feasability of sub-leasing a portion of the Academy space. Additionally, NTSB should conduct a study to determine the cost and 

feasability of moving certain functions from headquarters to the 

Academy facility in preparation for renegotiating the headquarters 

lease, which expires in 2011. We also recommend that NTSB develop a core investigative curriculum for each mode, and deliver 

that training at the Academy. 

Chairman Burns, Senator Lautenberg, we believe that the extent 

to which NTSB continues to address these types of management 

issues, will become increasingly critical if NTSB is to continue to 

carry out its safety mission and maintain its world-class status and 

preeminent position in the field. Thank you, Mr. Chairman, Senator Lautenberg. 

[The prepared statement of Dr. Dillingham follows:] 

PREPARED STATEMENT OF GERALD L. DILLINGHAM, PH.D., DIRECTOR, PHYSICAL

INFRASTRUCTURE ISSUES, UNITED STATES GOVERNMENT ACCOUNTABILITY OFFICE

(GAO) 

Mr. Chairman and members of the Subcommittee: 

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

Transportation Safety Board (NTSB). NTSB is a relatively small agency that plays 

a vital role in transportation safety. With a staff of about 400 and a budget of $76.7 

million in Fiscal Year 2006, NTSB is charged with investigating every civil aviation 

accident in the United States and significant accidents in the other modes—railroad, 

highway, marine, and pipeline—determining the probable cause of these accidents 

and issuing recommendations to address safety issues identified during accident investigations. NTSB has gained a worldwide reputation as a preeminent agency in 

conducting transportation accident investigations. Since 1967, it has issued 1,340 

major accident investigation reports, over 130,000 brief accident reports, and made 

13 

over 12,000 safety recommendations. To support its mission, NTSB built a training 

academy that opened in 2003 and provides training to NTSB investigators and other 

transportation safety professionals, including those from foreign countries. It is critical that the agency uses its resources in an efficient manner to carry out its safety 

mission and maintain its preeminent position. For this reason, you asked us to conduct a comprehensive review of NTSB’s management functions such as strategic 

planning, human capital management, and mission-critical investigation activities. 

My testimony today is based on our ongoing work for you, and it addresses the extent to which NTSB is: (1) following leading practices in selected management 

areas; (2) addressing challenges in completing accident investigations and closing 

safety recommendations; and (3) generating sufficient revenues to cover costs at its 

academy. We will be reporting additional results of our ongoing work to the Committee later this year. 

In summary: 

• While NTSB has recently made progress in following leading management practices, its overall record is mixed. For example, NTSB generally follows leading 

practices in the area of financial management. Over the last several years, 

NTSB has hired a Chief Financial Officer and improved its financial management by putting controls on its purchasing activities, which should address past 

problems with unapproved purchases with government credit cards. However, 

NTSB lacks a full cost accounting system, which would inform managers of the 

resources spent on individual investigations and provide data to help assure 

balanced office workload. Other areas, such as performance management, 

human capital, and communications, partially follow leading practices. For example, NTSB has begun to develop a performance management system that 

should eventually link each individual’s performance to the agency’s strategic 

goals and objectives. However, the performance management system will not be 

fully functional until NTSB has a strategic plan with results-oriented objectives 

and specific strategies for achieving them, which are lacking in the current strategic plan. In the area of human capital management, NTSB has recently developed a draft staffing plan that addresses the agency’s skills and competencies 

needs and includes strategies to increase the number of investigators and thereby strengthen the agency’s ability to carry out its transportation safety mission. 

However, the draft plan does not address organizational structure or the balance between supervisory and nonsupervisory positions. While NTSB has recently taken positive steps to improve communications from senior management 

to the staff—such as periodically sending e-mail to all staff to share information 

on new developments and policies—the agency does not regularly hold general 

staff meetings or undertake anonymous surveys to obtain employee feedback. 

• NTSB is accomplishing its accident investigation mission, but it faces challenges that affect the efficiency of the report production and recommendation 

close-out processes. In terms of accomplishing its mission, since its inception in 

1966, NTSB has investigated over 134,000 transportation accidents, and 82 percent of its recommendations have been implemented, or acceptable progress toward implementation has been made. However, investigations are often—sometimes necessarily—lengthy; NTSB routinely takes longer than 2 years to investigate major accidents. Lengthy investigations, combined with lengthy processes 

for federal agencies to regulate and industries to implement NTSB’s safety recommendations, can work against the goal of improving transportation safety. 

One factor that adds to the duration of investigations is that when new investigations are launched, inspectors are pulled from working on previous accidents to work on new ones. Other factors that may affect the duration of report 

production include the multiple revisions of draft investigation reports at different levels in the organizations and resource issues. NTSB has recently taken 

several actions that may help shorten report development time, such as reemphasizing its policy on holding report development meetings to obtain early buyin on report messages and holding modal directors accountable for specific 

issuance dates. We also identified practices in certain offices, such as the use 

of a project manager or deputy investigator-in-charge to handle report production, which may improve the efficiency of report development if used by all 

modal offices as they all are similar in what they do. The processes for implementing NTSB’s safety recommendations, and for NTSB to change the status 

of recommendations are also lengthy and labor intensive. As a result, unsafe 

conditions may continue to exist until federal transportation agencies, and ultimately, transportation industries, fully implement the recommendations, and 

the extended period it takes to change the status of recommendations ties up 

NTSB’s scarce resources. As of May 2006, 305 of the 852 open recommendations 

14 

have been in open status for 5 years or more. While Department of Transportation (DOT) officials have been working with NTSB to find acceptable means 

of implementing its recommendations, they cite the lengthy rule-making process 

as a challenge to speedy implementation. In addition, the process that NTSB 

uses to change the status of safety recommendations is paper-based, labor intensive, and relies on a series of sequential reviews that can take months to 

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

agency officials told us they remain unaware whether their response has been 

accepted or not accepted. 

• For Fiscal Years 2004 and 2005, NTSB’s academy did not generate sufficient 

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

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

other sources—approximately $6.3 million in Fiscal Year 2004 and $3.9 million 

in Fiscal Year 2005—were offset by general appropriations to the agency. Although there is no statutory requirement that revenues from NTSB’s academy 

generate sufficient revenues to cover the costs, NTSB was encouraged in the 

Senate report accompanying the Fiscal Year 2006 DOT Appropriations Act to 

be more aggressive in imposing and collecting fees to cover the costs. While 

NTSB has taken action to generate revenue from other sources, such as renting 

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

optimize opportunities for additional revenues at the academy. Additionally, 

NTSB is missing opportunities to find other uses for academy space. For example, during Fiscal Year 2005, less than 10 percent of the total classroom space 

was used. About 14 percent of the academy students in Fiscal Year 2005 were 

NTSB employees. However, in 2006, NTSB employees are scheduled to take 97 

percent of their requested training from sources other than the academy, such 

as DOT’s Transportation Safety Institute. The academy is not utilized more by 

NTSB staff, in part, because the agency has not developed a core curriculum 

for its staff, which it could then offer at the academy. Furthermore, many academy courses are similar to those taught elsewhere, which may affect the agency’s ability to attract non-NTSB students. 

Background 

NTSB was established in 1966 as an independent government agency located 

within the newly formed DOT.1 In 1974, Congress made NTSB completely separate 

from DOT.2 NTSB’s principal responsibility is to promote transportation safety by 

investigating transportation accidents, determining the probable cause, and issuing 

recommendations to address safety issues identified during accident investigations. 

Unlike other transportation agencies, such as the Federal Aviation Administration 

(FAA), NTSB does not have the authority to promulgate regulations to promote safety, but makes recommendations in its accident reports and safety studies 3 to other 

agencies that have such regulatory authority. The federal agencies that receive 

NTSB recommendations include the DOT’s FAA, Federal Highway Administration 

(FHWA), Federal Motor Carrier Safety Administration (FMCSA), Federal Railroad 

Administration (FRA), Federal Transit Administration (FTA), National Highway 

Traffic Safety Administration (NHTSA), Pipeline and Hazardous Materials Safety 

Administration (PHMSA), and the U.S. Coast Guard. NTSB also makes recommendations to others, such as state transportation authorities and industries. As 

Figure 1 indicates, NTSB has varying degrees of flexibility in its statutory mandate, 

as it pertains to initiating an investigation. By statute, NTSB has limited discretion 

in deciding which aviation accidents to investigate and the greatest amount of discretion to investigate highway accidents. 

15 

NTSB is comprised of a five member board—a Chairman, Vice Chairman, and 

three Members—appointed by the President with the advice and consent of the Senate.4 The Chairman is NTSB’s Chief Executive and Administrative Officer. As of 

March 2006, the Board was supported by a staff of 396, which includes 210 investigators assigned to four modal offices—aviation; highway; marine; and rail, pipeline, hazardous materials. (See Fig. 2.) The agency is headquartered in Washington, 

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

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

size due to budget constraints, which it has largely dealt with by using attrition to 

downsize the staff. In 2003, NTSB had 438 full-time employees compared with the 

current level of 396. During the same period, the number of full-time investigators 

decreased from 234 to 210. NTSB’s modal offices vary in size, with the aviation office having 125 employees; the rail, pipeline, and hazardous materials office having 

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

May 2006. An additional 42 employees work in the Office of Research and Engineering, which provides technical, laboratory, analytical, and engineering support for the 

modal investigation offices. For example, it is responsible for interpreting data recorders, creating accident computer simulations, and publishing general safety studies. NTSB’s budget increased from $62.9 million in Fiscal Year 2001 to $76.7 million 

in Fiscal Year 2006, or about 22 percent. After adjusting for inflation, this represents an increase of about 9 percent. The President has requested $79.6 million 

for NTSB in Fiscal Year 2007. 


524DILL1.eps
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Since 1966, NTSB has investigated over 124,000 aviation accidents and over 

10,000 surface transportation accidents. Figure 3 shows the total number of aviation 

investigations that NTSB has undertaken over the past 6 years and the degree to 

which NTSB was involved in the investigations. NTSB lacks the resources to conduct on-scene investigations of all aviation accidents. As a result, for general aviation accidents, NTSB delegates the gathering of on-scene information to FAA investigators, as allowed by statute.5 In these limited investigations, FAA sends the accident information to NTSB, and NTSB then determines a probable cause for the accident. In addition, NTSB participates in the investigations of foreign aviation accidents in conformance with Annex 13 of the International Civil Aeronautics Organization Treaty. These investigations involve a U.S. carrier or U.S.-built aircraft, or 

occur at the request of a foreign government. NTSB aviation investigators told us 

that there is often significant value in participating in such investigations; the findings often have safety implications for U.S. carriers, since most foreign airlines use 

U.S.-made aircraft, engines, and other parts and multiple foreign air carriers operate within the United States. 


524DILL2.eps 524DILL3.eps
17 

NTSB Has Made Recent Progress in Following Leading Management 

Practices, But Overall Record Remains Mixed 

Through our work government-wide we have identified a number of key functional 

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

This testimony focuses on NTSB’s performance in five key functional areas—strategic planning, performance management, human capital, financial management, 

and communications—and how NTSB’s practices compare to leading practices in 

those areas. As illustrated in Figure 4, NTSB, generally, is following leading practices in financial management, only minimally following leading practices in strategic planning, and has mixed results for the other functions. Much of NTSB’s 

progress toward following leading practices is due to recent management initiatives. 

The report we will be issuing later this year, will provide additional information on 

NTSB’s performance relative to these five management functions, as well as information technology, acquisition management (including the agency’s use of contracting), knowledge management, and capital decisionmaking. 

NTSB’s Strategic Plan Lacks Certain Performance-Based Elements and Performance 

Management Plans Closely Follow Leading Practices But Are Not Fully 

Functional 

The Congress and the President have encouraged better management of federal 

agencies by means such as results-oriented strategic planning, but NTSB’s strategic 

plan generally does not follow performance-based practices. Without effective shortand long-term planning, federal agencies risk delivering programs and services that 

may or may not meet the Nation’s most critical needs. The Government Performance and Results Act of 1993 (GPRA) 6 and guidance contained in the Office of Management and Budget’s (OMB) Circular A–11, provide performance-based strategic 

planning guidelines. GPRA was intended to achieve several broad purposes, including improving federal program effectiveness, accountability, and service delivery, 

and enhancing Congressional decisionmaking by providing more objective information on program performance. GPRA requires federal agencies to develop strategic 

plans in which they define their missions, establish results-oriented goals, and identify the strategies that will be needed to achieve those goals. For instance, GPRA 

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

set objectives and goals that are specific outcomes that the organization wishes to 

accomplish (called outcome-related objectives). 

To its credit, in December 2005, NTSB issued a strategic plan for the years 2006 

through 2010, which was the first time the agency had a strategic plan in 6 years. 


524DILL4.eps
18 

In developing that plan, senior agency officials told us that they modeled their plan 

on examples from other federal agencies with similar structure and mission, such 

as the Federal Communications Commission. We compared NTSB’s strategic plan 

to selected elements required by GPRA. (See Fig. 5.) 

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

and related objectives, and mentions key factors, such as declining resources, that 

could affect the agency’s ability to achieve those goals, the plan lacks a number of 

key elements—including information about the operational processes; skills and 

technology; and the human capital, and information resources—required to meet the 

goals and objectives. In addition, the goals and objectives lack sufficient specificity 

to know whether they have been achieved. One goal states ‘‘NTSB will maintain its 

response capacity for investigation of accidents and increase its analysis of incidents.’’ An objective of that goal is to ‘‘continuously assess the most robust and efficient approaches to accident investigation.’’ Although such a goal is important for 

the safety of the transportation industry, this and the other three goals, and related 

objectives, are not measurable. As a result, it will be difficult for NTSB and others 

to determine if the goals have been achieved. 

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

to GPRA, the strategies should include a description of the operational processes, 

skills and technology, and the resources required to meet the goals and objectives. 

Since NTSB’s strategic plan lacks such a description, it does not align staffing, 

training, or other human resource management to strategic goals. That is, the plan 

does not explicitly explain how NTSB will use its resources to meet its mission and 

goals. While the plan explains that each program office has its own objectives linked 

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

how each office contributes to those goals and objectives. In addition, NTSB’s strategic plan does not describe how the performance goals contained in the annual performance plan are related to the general goals and objectives in the strategic plan, 

as required by GPRA. 

GPRA also requires federal agencies to provide a description in their strategic 

plans of the program evaluations used in establishing or revising general goals and 

objectives and a schedule for future program evaluation. NTSB’s strategic plan lacks 

this information. As a result of having no program evaluations, it is unclear how 

or whether NTSB reviews its efforts to identify strengths it can maximize and weaknesses it should address. In developing a strategic plan, GRPA requires agencies to 

consult with Congress and other stakeholders. We have previously reported that 

other stakeholders of federal agencies include state and local governments, other 

federal agencies, interest groups, and agency employees. NTSB’s strategic plan does 

not mention consultation with any stakeholders in its development. Furthermore, 

board members and agency staff told us that they had no involvement in the develVerDate Nov 24 2008 11:11 Aug 03, 2011 Jkt 067624 PO 00000 Frm 00022 Fmt 6633 Sfmt 6621 S:\GPO\DOCS\67624.TXT SCOM1 PsN: JACKIE

524DILL5.eps
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opment of the strategic plan. Some current and past board members additionally 

stated that they believed that their involvement would be beneficial in providing a 

strategic vision for the agency. NTSB’s senior management told us they expect to 

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

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

NTSB has begun to develop a performance management system that should eventually link each individual’s performance throughout the agency to the agency’s 

strategic goals and objectives. We have reported that performance management systems are crucial for agencies because if developed properly they allow employees to 

make meaningful contributions that directly contribute to agency goals.7 NTSB has 

developed a comprehensive performance management plan for Senior Executive Series (SES) employees that links individual performance to strategic goals. Furthermore, the plan states that NTSB will link performance management with the agency’s results-oriented goals and set and communicate individual and organizational 

goals and expectations. 

This plan establishes individual performance criteria and the appraisal process. 

The appraisal process defines performance standards and explains performance elements that determine individual ratings. Because NTSB recognizes in this plan the 

importance of aligning organizational performance with individual performance and 

contributions to the agency’s mission, the performance management plan is a step 

in the right direction. 

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

its overall workforce, which includes some elements of linking individual performance to organizational goals. However, without having results-oriented goals in the 

strategic plan itself, neither of the two performance management plans are fully 

functional. That is, until NTSB’s goals are more fully articulated in the strategic 

plan, it will be impossible for staff to know whether their performance contributes 

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

the development of the performance plan, and there was no mechanism for employee feedback after the plan was initially developed. Employee involvement provides greater assurance that policies are accepted and implemented because employees had a stake in their development. 

NTSB’s Staffing Plan Is a Step in the Right Direction, But the Organizational 

Structure Has Not Been Reviewed 

NTSB developed a draft agencywide staffing plan in December 2005, that follows 

several leading practices, but lacks a workforce deployment strategy that considers 

the organizational structure and its balance of supervisory and non-supervisory positions. Existing strategic workforce planning tools and models suggest that certain 

principles should be followed in strategic workforce planning, such as determining 

the agency’s skills and competencies needs; involving stakeholders (e.g., management and employees) in the planning process; and developing succession plans to 

anticipate upcoming employee retirement and workforce shifts.8 Further, in workforce deployment, it is important to have human capital strategies to avoid excess 

organizational layers and to properly balance supervisory and nonsupervisory positions.9 NTSB’s draft staffing plan addresses the agency’s skills and competencies 

needs and includes strategies to deal with workforce shifts. For example, the staffing plan proposes to increase the number of investigative staff by 21, which will 

help with the agency’s resource needs. In addition, while some stakeholders (i.e., 

managers) were involved in the planning process, employees were not included. As 

we mentioned previously in this testimony, employee input provides greater assurance that policies are accepted and implemented because employees have a stake 

in their development. 

To develop the staffing plan, each modal office director submitted to NTSB’s Managing Director an ideal staff size for his office, including additional slots for investigators. The increase in investigative staff is consistent with requests by modal offices to enhance their ability to conduct their investigative mission. Managers told 

us that current staffing constraints inhibited their ability to conduct more accident 

investigations and indicated an increase in staff would be helpful. For example, directors of the highway and rail/pipeline offices told us they could not initiate investigations on more than two accidents at a time because they lacked sufficient investigative staff to do more.10 The modal office directors’ request for staff resulted in 

a total agency allotment of 455 full time equivalents (FTEs) plus 20 co-op positions. 

The Managing Director reduced this number to 404, which corresponds to NTSB’s 

current funding level of 395, allowing for attrition and turnover. The Managing Director’s allocation resulted in a proposed increase of 21 investigators agencywide 

and a proposed reduction of certain staff positions to accommodate the increase in 

investigators. This increase in investigative staff is consistent with a recommendaVerDate Nov 24 2008 11:11 Aug 03, 2011 Jkt 067624 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 S:\GPO\DOCS\67624.TXT SCOM1 PsN: JACKIE
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tion by RAND Corporation, which evaluated NTSB’s accident investigation process 

and workload in 1999.11 To help implement the realignment, senior managers told 

us that they would like to transition some existing administrative and support staff 

with appropriate background and training into investigator roles where possible. 

The draft plan set a target date of May 2006 to begin creating developmental opportunities for staff to transition to investigative roles and to develop reduction strategies for staff that fall outside the staffing plan. 

NTSB Lacks A Strategic Approach To Training Staff 

Training is another key area of human capital management. It is important for 

agencies to develop a strategic approach to training its workforce, which involves 

establishing training priorities and leveraging investments in training to achieve 

agency results; identifying specific training initiatives that improve individual and 

agency performance; ensuring effective and efficient delivery of training opportunities in an environment that supports learning and change; and demonstrating how 

training efforts contribute to improved performance and results.12 NTSB has not developed a strategic training plan, nor has it identified the core competencies needed 

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

of not having a core curriculum that is linked in this manner, NTSB lacks assurance that the courses that staff take provide the technical knowledge and skills necessary for them to be competent for the type of work they perform. 

Financial Management Is Improved, but NTSB Lacks a Full Cost Accounting System 

Sound financial management is crucial for responsible stewardship of federal re- sources.13 In recent years, NTSB has made significant progress in improving its financial management. In March 2001, NTSB hired a Chief Financial Officer who has 

emphasized the importance of sound financial management based on best practices. 

Similar to private-sector companies, government agencies are required to report 

their financial condition in publicly-available financial statements. As a result of actions taken by NTSB, the agency received an unqualified or ‘‘clean’’ opinion from 

independent auditors on its financial statements for the fiscal years ending September 30 for the years 2003, 2004, and 2005. The audit report concluded that 

NTSB’s financial statements presented fairly, in all material respects, the financial 

position, net cost, changes in net position, budgetary resources, and financing in 

conformity with generally accepted accounting principles for the three years. NTSB 

has also improved its purchasing and contracting activities after identifying problems in those areas in 1999. In 2001, DOT’s Office of Inspector General (DOTIG) 

reviewed the agency’s contracting and procurement activities and recommended that 

NTSB institute accountability and controls in its purchase card program as well as 

other purchasing activities. As a result of this and another DOTIG audit,14 NTSB 

has taken a number of initiatives to improve its purchasing and contracting activities. For example, NTSB restructured its purchase card system and guidelines to 

address problems, such as unrestrained and unapproved purchases on government 

credit cards. NTSB hired a manager of the contracting function to manage the agency’s acquisition function and implement the DOTIG recommendations. In our full report, we will analyze some of these initiatives in more detail. 

In 2000, RAND recommended that NTSB develop systems that would allow the 

agency to better manage its resources by permitting full-cost accounting 15 of all 

agency activities.16 To accomplish this, RAND recommended putting in place a 

timekeeping system, in which individual project numbers were assigned to each investigation and support activities such as training. With this information, project 

managers could better understand how staff resources were utilized and project 

workload could be actively monitored by the Managing Director. NTSB has begun 

to implement this recommendation by upgrading a software system in November 

2005 that tracks employee annual leave and sick leave. However, the system is not 

being fully utilized to track the number of hours staff spend on each investigation. 

Also, this system is not used to track time staff spend in training or at conferences. 

As a result, RAND’s previous conclusion that ‘‘NTSB managers have little information they can use to plan the utilization of staff resources or manage staff workloads 

properly’’ remains current. 

Communications From Senior Management To Staff Have Increased And 

Communications Among Offices Is Generally In Place, But Upwards 

Communications Mechanisms Are Lacking 

We have identified useful practices related to managing employees that include 

seeking and monitoring employee attitudes, encouraging two-way communication 

between employees and management, and incorporating employee feedback into new 

policies and procedures.17 In response to issues raised by NTSB employees in a government-wide survey conducted by OPM in 2004, NTSB’s senior management made 

21 

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

the Managing Director periodically sends ‘‘management advisory’’ e-mail to all staff 

that share information such as policy changes or new developments at the agency. 

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

such as town hall meetings, regular staff meetings, or anonymous employee surveys; 

or incorporated employee feedback into policy-making. 

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

on the effectiveness of communications within the agency.18 The four investigators 

from one modal office that we spoke with told us that they are pleased to now hear 

about policy changes at the agency, but said that there is too much reliance on the 

Internet for these communications. They also told us that although they believe the 

increased communications are positive, they found it difficult to find the time to 

read the material and still conduct their regular investigative duties. The four investigators that we spoke with from another modal office agreed that staff meetings 

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

their managers. Further, they said that new policies or agency issues are not discussed with staff prior to issuance, and there was no formal mechanism to provide 

feedback during the policies’ development. In the past, regular formal meetings occurred between union leadership and senior NTSB management, which allowed for 

such input, but that practice ceased. Although formal communication processes from 

the staff level to management are lacking, informal e-mail communications do take 

place occasionally between staff and senior management. 

Communication and collaboration across offices at all levels can improve an agency’s ability to carry out its mission by providing opportunities to share best practices 

and helping to ensure that any needed input is provided in a timely manner. We 

found that communication and collaboration between the Research and Engineering 

office and the modal offices appears to be regular. This is shown by the inclusion 

of Research and Engineering staff as core members of major investigative teams. 

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

number of projects that support all modes, and a Research and Engineering manager told us that his office frequently interacts with investigative staff. 

In contrast, NTSB lacks processes that would allow investigators and writer editors to communicate across the modal offices regarding the investigative process and 

other issues, according to staff we spoke to. The four investigators that we spoke 

with from one modal office told us that they are isolated from the rest of the agency 

and that lessons learned are not shared across offices. The investigators from another modal office told us that they are on permanent teams that share the same 

priorities in completing accident analysis, which enhances communication and teamwork in the office. In addition, in previous years, all writer editors were located in 

one group and reported directly to the Managing Director. Now, each modal office 

has its own staff of writers and editors. While they have retained personal working 

relationships from when they were located in the same office, four of the eight writer editors we spoke with said that they no longer share information with each other 

regularly.19 As a result, efficiencies and lessons learned that investigators and writer editor staff in one office might develop might not be shared with other offices. 

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

opportunity to meet with the publications specialist for training and to exchange information. 

NTSB Is Accomplishing Its Accident Investigation Mission, But 

Opportunities Exist to Gain Efficiencies 

While NTSB is accomplishing its accident investigation mission, it faces challenges that affect the efficiency of the report production and recommendation closeout processes. In terms of accomplishing its mission, since its inception, NTSB has 

investigated over 134,000 transportation accidents. Eighty-two percent of its recommendations have been ‘‘accepted,’’ a term NTSB uses to include recommendations 

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

been implemented. Figure 6 shows that highway recommendations have the highest 

acceptance rate and marine recommendations have the lowest. 

22 

NTSB Investigations Are Often Lengthy, in Part Because Investigators Must Launch 

New Investigations Before Completing Ongoing Investigations 

Investigations have four phases—the ‘‘launch,’’ fact finding, analysis, and report 

production. After a report is issued and recommendations made, the progress of implementing the recommendations is tracked during a fifth close-out phase. Figure 

7 describes these phases. 

Investigations are often lengthy and sometimes necessarily so. NTSB routinely 

takes longer than 2 years to complete major aviation investigations. For example, 

the total time to complete major aviation investigations has increased from an average of about 1.25 years in 1996 to an average of almost 3.5 years in 2006. (See Fig. 

8.) In 2004, NTSB contracted with Booz Allen Hamilton to examine and make recommendations to improve the report development process and the recommendation 

close-out process. Booz Allen Hamilton 20 reported that the average time to complete 

major investigations across all the modes was either 1.8 months or 1.9 months for 

4 out of 5 years.21 Lengthy investigations, combined with lengthy processes for federal agencies to develop regulations based on those recommendations and industries 

to implement the recommendations can work against the goal of improving transportation safety. 


524DILL6.eps 524DILL7.eps
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One factor that adds to the duration of investigations is that when new investigations are launched, investigators are pulled from working on previous accidents to 

work on new ones. For example, when a major commercial aviation accident occurs, 

an NTSB ‘‘go team’’ is dispatched from Washington, D.C., usually within hours of 

notification of the accident. In such cases, the team members must leave the investigations they had been working on to begin fact-finding on the new accident. In the 

cases of rail and highway accidents, NTSB investigators must also arrive quickly 

on-scene to gather information because the accident scenes will be cleared quickly 

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

ongoing reports would be delayed by 2 months if a sudden launch were to occur. 

The number of major investigations that are ongoing for each mode is shown in Figure 9. 


524DILL8.eps 524DILL9.eps
24 

Writing and Report Production Is a Bottleneck in the Process 

Another reason for the expansive time frame for accident investigations is that 

reports receive multiple revisions at different levels in the organization, including 

the office directors and the Managing Director’s office, prior to going to the board 

members for final voting and approval of the draft report. An investigation report 

typically goes through the following reviews: the modal office, the Office of Research 

and Engineering, the Executive Secretariat, the Office of Safety Recommendations, 

the Office of General Counsel, the Deputy Managing Director, the Managing Director’s office, and each Board Member and the Chairman. For any review, there may 

be multiple iterations. Eleven investigators and 6 writer editors told us that the review process often results in improved clarity for report recommendations.22 However, investigators and writer editors also told us that they believe the levels of 

management review and approval for written products are excessive. All eight writer editors agreed that the reviews by the Executive Secretariat’s office, which services a quality assurance function, was a bottleneck for getting products approved. 

They told us that it is common for correspondence and other products to be delayed 

in this office for 1 week or more, which they viewed as excessive. While it may be 

a reasonable expectation for short products, such as correspondence, to be reviewed 

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

Hamilton confirmed multiple iterations of review as the draft was routed through 

numerous offices. On average, Booz Allen Hamilton found that there were 7 levels 

of reviews within a given modal office that resulted in an average of 28 separate 

reviews. A senior NTSB official stated that the many levels of review were needed 

to get the appropriate perspectives from relevant offices that had been involved in 

report development, such as the Research and Engineering Office and Safety Recommendation Office. The official also noted that the process can be streamlined on 

a case-by-case basis in which the usual process of sequential reviews is replaced 

with concurrent reviews. The NTSB official told us that there are no explicit criteria 

for determining when the streamlined process could be used. 

NTSB staff with whom we spoke reported that resource issues contributed to 

other bottlenecks. For example, four writer editors pointed out that NTSB has only 

one final layout and typesetting person. As of May 2006, the final layout process 

had a backlog of approximately 10 reports that have been approved for issuance at 

Board meetings, but have not yet been published. NTSB adopts about 2 reports a 

month and issues on average 4 reports a month. In addition, some investigators 

have the perception that the workload of writer editors is another bottleneck. For 

example, one investigator told us that he submitted draft reports to the senior writer editor in September 2005, and as of April 2006, no additional writing had been 

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

worked on five or more products at one time. 

Certain Agency Practices May Help Shorten Report Development 

NTSB has recently taken several actions that, along with potentially better practices in one modal office, may help shorten report development time. First, in response to a recommendation by Booz Allen Hamilton to gain management’s buy-in 

to the report message before writing the report and thereby reduce the number of 

review iterations, NTSB management has reemphasized its policy for report development meetings. NTSB has a long-standing order that calls for holding message 

development meetings with internal stakeholders who will be reviewing the report 

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

stopped following that policy before Booz Allen Hamilton conducted its study in 

2004. The official further stated that subsequent to that recommendation, NTSB’s 

Managing Director sent a memorandum reminding staff to follow the policy. While 

NTSB has no data on whether the message development meetings are actually taking place, officials told us that the Managing Director’s recent emphasis on these 

meetings was resulting in more of them occurring than in previous years. 

Second, since the Spring of 2005, NTSB has initiated production meetings with 

senior management with the goal of reducing the duration of investigations. These 

meetings occur every 2 weeks and focus on report development and production. 

NTSB modal directors are held accountable for a specific issuance date within a six 

month planning window prior to issuing a report. During the bi-weekly meetings, 

the directors discuss with NTSB’s Managing Director and senior executives their 

progress and commitments to complete the investigations. The meetings result in 

a production schedule that is available for subsequent review. The modal directors 

stated that they believe the new system is effective in reducing the duration of investigations; however because these meetings began so recently, it is too early to 

evaluate their effectiveness. 

25 

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

completion—uses a concept called a ‘‘project manager,’’ who serves as a supervisory 

writer editor and interface between the investigative staff and the writer editor 

staff. As a result, the project manager assumes some of the report development roles 

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

draft report to the writer editor, who then edits and sometimes substantially rewrites the report. In aviation, investigators-in-charge do not write reports, but rather writer editors develop the final report from interim technical reports drafted by 

specialists on the team. Booz Allen Hamilton recommended that all modes use a 

project manager or deputy investigator-in-charge so that the expertise of staff can 

be used more fully. In addition, such a practice might alleviate some of the workload 

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

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

it or developed any milestones for implementation. 

Fourth, the highway safety office uses an incentive system for performance on developing reports. Booz Allen Hamilton reported the highway safety office rewards 

staff with a cash bonus for meeting key deadlines for producing accident reports. 

Again, the study recommended that the highway program be used as a model for 

the other modal offices. The study further recommended that the incentive program 

be slightly modified so that the incentives are based on delivering reports before 

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

would be tightened and the overall report development time would be shortened. According to NTSB officials, they are currently examining how to implement improved 

awards and incentive programs that will result in improved quality and timeliness 

of report products. 

Safety Recommendations Close-out Process Is Time Consuming for Several Reasons 

The processes for federal transportation agencies to implement NTSB’s safety recommendations, and for NTSB to change the status of recommendations it has made, 

are also lengthy because of complex processes involving many players. As of May 

2006, 305 of NTSB’s 852 open recommendations had been open for 5 years or more. 

Lengthy processes for federal agencies to develop regulations to implement NTSB’s 

safety recommendations and industries to comply can work against the goal of 

quickly improving transportation safety. In addition, the lengthy, paper-based process for changing the status of recommendations ties up NTSB’s scarce resources. 

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

challenges faced by federal transportation agencies in implementing those recommendations, particularly those that require changes to federal regulations, which 

take many years to complete. DOT modal officials with whom we spoke cited a 

lengthy rulemaking process, which includes budgeting and allocating resources to 

develop the proposed regulation, drafting and receiving comments on proposed rules, 

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

example, TWA flight 800 crashed off Long Island in July 1996; NTSB issued safety 

recommendations pertaining to explosive fuel tanks in December 1996. NTSB adopted the accident report with further recommendations to FAA to reduce flammable 

vapors in aircraft fuel tanks in 2000; FAA issued a notice of proposed rule to address this recommendation in November 2005; the comment period for the notice 

ended on March 23, 2006. Thus, 10 years after the crash, the final rule has not been 

issued. Federal transportation officials also said the failure to satisfy a cost-benefit 

analysis might impede the implementation of NTSB recommendations. Although 

NTSB is required to only consider the safety implications of its recommendations 

and not consider the cost factors, if a proposed regulation is not cost beneficial, it 

cannot be approved by OMB. 

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

recommendations, indicated that they have been working with NTSB to find acceptable means of implementing recommendations. The process—recently called Safety 

With a Team—is designed for NTSB and federal agencies to work in cooperation to 

address open recommendations and implement needed safety improvements. NTSB 

and DOT officials told us that this process contributed to the closing of many recommendations. However, the process is not used with the Coast Guard, which has 

the lowest rate—74 percent—for accepting NTSB recommendations among the 

modes, as mentioned previously. According to a Coast Guard official we spoke with, 

the Coast Guard believes that it has an acceptable rate for closing NTSB recommendations and that it does not intend to act on recommendations that it 

deemed unnecessary. 

NTSB recognizes that open recommendations can have serious safety implications 

for the transportation industry. To spur implementation, the agency also publishes 

26 

a ‘‘most wanted’’ list of what it considers the most serious safety concerns. For example, in 2000, NTSB added to its most wanted list the need to improve the safety 

of motor carrier operations. NTSB recommended that FMCSA prevent motor carriers from operating if they put vehicles with mechanical problems on the road or 

unqualified drivers behind the wheel. As recently as May 2006, NTSB issued an additional recommendation that FMCSA ‘‘establish a program to verify that motor carriers have ceased operations after the effective date of revocation of operating authority.’’ 

The process that NTSB uses to change the status of or close out safety recommendations is paper-based, labor intensive, and relies on a series of sequential 

reviews; this process can take between 6 and 12 weeks. As a result, NTSB is delayed in communicating with agencies on whether NTSB considers the actions that 

have been taken to address the recommendation are sufficient to accept the recommendation. Consequently, agencies remain unaware that their response has been 

accepted or not accepted. And in the case of DOT, this lack of information affects 

its ability to accurately report annually to Congress on the status of implementing 

NTSB’s recommendations in all its modal administrations.23

The process of closing recommendations is managed by NTSB’s Safety Recommendation Office, which has responsibility for maintaining a recommendations 

database and administering the paper flow to change the status of recommendations. Adding complexity to the process—which NTSB calls the ‘‘mail control process’’—is the fact that there are 12 separate categories of recommendations status. 

The 12 categories are listed in Figure 10, which also shows the percentage of recommendations in each category as of May 1, 2006. 

The process begins when NTSB receives documentation from the recommendation 

recipient that would change the recommendation’s status. The Safety Recommendation Office generates paper folders and supervises a process that is summarized in 

Figure 11. This process involves multiple, sequential approvals starting from the 

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

Office, to the Managing Director’s office, to the Board Members for final approval. 

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


524DILL10.eps
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at any given time, according to the Director of the Safety Recommendations Office. 

There are no electronic communications or approvals throughout the process. In its 

study of NTSB, Booz Allen Hamilton identified this as an inefficient process. Officials at NTSB agree that efficiencies could be gained in this process and are considering eventually computerizing a number of processes such as this one. The agency 

expects to develop such plans after hiring a Chief Information Officer later this 

year. 

NTSB’s Academy Does Not Generate Sufficient Revenues to Cover Costs 

and Is Not Fully Utilized 

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

would generate sufficient revenues to cover the costs, in July 2005, NTSB was encouraged in the Senate report accompanying the Fiscal Year 2006 DOT Appropriations Act to be more aggressive in imposing and collecting fees to cover the costs.24

The academy generates revenues through tuition fees, space rental to other agencies 

for events such as conferences, and contracts with federal agencies that would allow 

them to use academy space for ‘‘continuity of operations’’ in emergency situations. 

To the extent that NTSB maximizes the use of the academy, it can produce additional revenues that may help cover costs. 

Academy Costs Have Exceeded Revenues 

For the first 2 full years of operation, Fiscal Years 2004 and 2005, NTSB’s academy did not generate sufficient revenues to cover the costs of providing training, as 

shown in Table 1. As a result, those portions of the academy’s costs that were not 

covered by the revenues from tuition and other sources—approximately $6.3 million 

in Fiscal Year 2004 and $3.9 million in fiscal year 2005—were offset by general appropriations to the agency. The salaries and other personnel related expenses associated with NTSB investigators and managers teaching at the academy, which 

would be appropriate to include in academy costs, are not included in Table 1 because NTSB told us that it does not choose to account for expenses in that manner. 

In addition, NTSB lacks a full cost-accounting system that would facilitate doing so. 

The table shows expenses directly associated with the academy and does not include 

an allocation of agency wide supporting services, such as the Managing Director’s 

office, information technology, human resources, and legal support. Some of the expenses during these 2 years were one-time expenses—such as over $125,000 for furniture and equipment (included in Table 1 as office supplies for Fiscal Year 2005) 

and $499,000 to move the wreckage of the TWA flight 800 airplane from storage 

near the crash site in New York to the academy (included in the table as miscellaneous government contract services in Fiscal Year 2004). Space rental is a fixed annual expense of about $2.5 million. When that fixed expense is excluded from academy expenses, the remaining operating expenses exceeded revenues by about $3.7 

million in Fiscal Year 2004 and about $1.4 million the subsequent year. 


524DILL11.eps
28 

In addition, while some courses presented during the first 2 years of academy operation did not recover the costs that NTSB attributes to them, revenues from other 

courses exceeded the cost. Of the 49 class sessions provided at the academy in Fiscal 

Years 2004 and 2005, revenues from 14 sessions, all of which occurred in Fiscal 

Year 2005, did not recover their cost, while revenues from the remaining sessions 

exceeded the cost.25 According to the academy’s Deputy Manager, courses are only 

expected to generate enough revenues to offset the costs specifically attributed to 

the course, with some additional allocation for research and development of other 

programs and, if possible, other academy costs. Accordingly, tuition prices are determined by estimating those costs (such as course material, contracted instructors and 

their travel expenses) and dividing that cost by the projected class size. Costs such 

as the building lease, maintenance, building security, and academy personnel are 

not allocated to the costs of individual courses.26 In addition, consideration is given 

to setting tuition at a level that is competitive with similar courses by other institutions and that is not prohibitively high for prospective students from government 

agencies, according to the academy official. 

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

of the academy. For Fiscal Year 2004, over $12,000 in revenue (about 5 percent of 

total revenues) was collected from sources other than course fees to cover some of 

those costs. For Fiscal Year 2005, the revenue from other sources increased to over 

$91,000 (about 14 percent of total revenues). Other sources of income during these 

2 years included renting space to other organizations, such as the Society of Automotive Engineers, George Washington University, and the National Association of 

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

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

Commission and the Virginia Circuit Courts—for continuity of operations. According 

to NTSB officials, it has explored this option with other organizations, but has not 

found others who will pay a yearly retainer for the service.27 While NTSB has taken 

action to generate revenue from other sources, it does not have a business plan or 

marketing strategy that seeks to optimize opportunities for additional revenues. According to the academy’s Deputy Manager, NTSB plans to develop a business plan. 

The agency, however, has no time-frames for doing so. 

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

the facility in other ways to generate revenues or potentially reduce costs. For example, the lease does not preclude NTSB from subletting unused space to other 


524DIL11A.eps
29 

users. Since certain space is already configured as classrooms and the academy is 

located in an academic setting on George Washington University’s suburban Virginia campus, it may be possible to market space to academic users. Furthermore, 

NTSB is not precluded by its academy lease or its lease for headquarters space in 

Washington, D.C., from relocating some headquarters staff to the Virginia facility. 

The lease for the office space in Washington, D.C., expires in 2011. Such a move, 

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

and equipment, reconfiguring space and utilities, as well as recurring travel costs 

for staff who must travel between the two locations. Such costs would have to be 

weighed against the reduced cost of leasing less space in Washington, D.C. 

Academy Classrooms Are Significantly Underutilized 

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

revenues that may help cover costs.28 We estimate that, overall, less than 10 percent of the total classroom space was used during Fiscal Year 2005.29 As shown in 

Figure 12, none of the five classrooms were used for 21 weeks in Fiscal Year 2005. 

In addition, at any given time, no more than three classrooms were in use. Figure 

12 shows the days in which classroom space was used for 31 class sessions and 12 

other events, such as workshops and seminars by organizations that rented the 

space during Fiscal Year 2005. 

While a relatively small percentage of the academy’s students have been NTSB 

staff, the agency is taking efforts to increase their enrollment at the academy. About 

20 percent of the academy’s approximately 1,000 students 30 in Fiscal Year 2004 

were NTSB staff, and about 14 percent of the 1,400 students in Fiscal Year 2005 

were NTSB staff. Over the 2 years, about 400 NTSB students 31 attended 38 of the 

49 class sessions conducted at the academy during Fiscal Years 2004 and 2005. (See 

Fig. 13) NTSB is making efforts to have staff more fully utilize the facility. In Fiscal 

Year 2004, 1 of 18 sessions was only for NTSB investigators; in Fiscal Year 2005, 

5 of 31 sessions were only for NTSB investigators.32 While increasing the use of the 

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


524DILL12.eps
30 

it is important that NTSB not reduce the number of external, paying students in 

the process. 

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

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

staff training requests for Fiscal Year 2006 showed that 97 percent of all training 

is expected to be from external sources and the remaining training from NTSB’s 

academy. NTSB staff have requested external training being provided by organizations that include FAA’s Transportation Safety Institute, the University of Southern 

California, the U.S. Department of Agriculture, and Kettering University for training in subjects such as human factors in aviation safety, turbine engine investigation, or automotive design and safety. Training requests cover other specialties such 

as helicopter training, flight training currency for pilots, technical writing, supervisory and management skills, and industry conferences. Investigators and writer 

editors with whom we spoke had positive views on the quality of academy training 

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

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

taught) courses at the academy and thought the courses were excellent; 33 none of 

the investigators and writer editors had anything negative to say about the quality 

of any academy course. However, none of the staff we talked with had plans to attend academy training in Fiscal Year 2007. One reason noted for this situation was 

the remoteness of Ashburn, Virginia, from their residences. Another reason was the 

lack of courses on new transportation technologies and the skills and competencies 

needed by an investigator-in-charge. Eight investigators told us that they find workshops by manufacturers, such as aircraft and automobile manufacturers, more valuable to their work than academy training. 

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

not developed a core curriculum for its staff that could then be offered at the academy, as mentioned previously in this testimony. The academy only offers one course 

that is required for NTSB staff—a 2-week course on aviation accident investigation 

that is required for new NTSB investigator staff. The Deputy Manager of the academy told us that the academy plans to eventually offer more internal training covering subjects such as management skills, retirement, and computers.34 However, 

no milestones or specific plans have been established for that effort. 

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

can affect the agency’s ability to attract additional outside students. First, the lack 


524DILL13.eps
31 

of a business or marketing plan may be affecting NTSB’s ability to fully utilize the 

academy. Second, academy training is similar to training provided by other institutions. FRA, FAA, and PHMSA officials told us that their investigators do not attend 

NTSB training because similar training is provided in-house by DOT’s Transportation Safety Institute. For example, an FAA investigator told us that new investigators take a basic accident investigation course at the Transportation Safety Institute and subsequently take mid-career follow-up courses there. Furthermore, our 

comparison of NTSB’s Fiscal Year 2006 curriculum with that of several other institutions that teach courses on accident investigations showed that other institutions 

offered courses similar to 12 of NTSB’s 19 courses. For example, DOT’s Transportation Safety Institute offers basic courses on aviation and bus accident investigations, and the University of Southern California offers a course on human factors 

related to accident investigations. 

Additional Issues Concerning the Academy 

You asked that we provide information concerning the academy’s use of NTSB investigators as instructors and NTSB’s compliance with the Anti-Deficiency Act, with 

regard to its accounting for its academy lease. Concerning the first issue, academy 

courses are taught by a combination of academy staff, NTSB investigators and managers, and contractors. Use of investigators as instructors is limited and is likely 

to have little impact on investigators’ overall workload. During Fiscal Year 2005, 51 

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

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

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

than a capital lease. As a result, NTSB has been noncompliant with the Anti-DefiVerDate Nov 24 2008 11:11 Aug 03, 2011 Jkt 067624 PO 00000 Frm 00035 Fmt 6633 Sfmt 6621 S:\GPO\DOCS\67624.TXT SCOM1 PsN: JACKIE

524DILL14.eps
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ciency Act because it did not obtain budget authority for the net present value of 

the entire 20-year lease obligation at the time the lease agreement was signed in 

2001. NTSB realized the error in 2003 and reported its noncompliance to Congress 

and the President. NTSB has proposed in the President’s Fiscal Year 2007 budget 

to remedy this Anti-deficiency Act violation by inserting an amendment in their Fiscal Year 2007 appropriation, that would allow NTSB to fund this obligation from 

their salaries and expense account through Fiscal Year 2020. 

Conclusions 

Mr. Chairman, we have developed several conclusions from our analysis of NTSB 

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

progress toward following leading practices is due to recent management initiatives. 

The performance management plan, draft staffing plan, and implementation of controls over financial transactions are all positive steps. NTSB’s progress in these 

areas will likely remain incomplete without additional actions, however. For example, without a more comprehensive strategic plan than it currently has, NTSB cannot align staffing, training, or other human resource management to its strategic 

goals or align its organizational structure and layers of management with the plan. 

NTSB will also likely miss opportunities to strengthen the management of the agency until it develops a strategic training plan for its employees, implements a full 

cost-accounting system, and improves communications within the agency. 

We have also concluded that, despite the many safety recommendations NTSB 

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

resulted from the process that the agency uses to close out safety recommendations. 

In particular, the absence of a computerized documentation system and the sequential reviews that NTSB currently requires slow the process and prevent expedient 

delivery of information about recommendation status to affected agencies. Finally, 

in terms of its academy, NTSB is missing opportunities to increase the value of this 

asset. Without a comprehensive marketing plan, NTSB will likely be unable to efficiently attract users who would help pay the ongoing costs of the facility. 

Recommendations for Executive Action 

To improve the efficiency of agency operations, we are making eight recommendations to the Chairman of the National Transportation Safety Board based on our 

completed work to date. To improve agency performance in the key functional management areas of strategic planning, human capital planning, financial management, and communications, we recommend that the Chairman implement the following three recommendations: 

• Improve strategic planning by developing a revised strategic plan that follows 

performance-based practices; developing a strategic training plan that is aligned 

with the revised strategic plan and identifies skill gaps that pose obstacles to 

meeting the agency’s strategic goals and curriculum that would eliminate these 

gaps; and aligning their organizational structure to implement the strategic 

plan and eliminate unnecessary management layers. 

• Develop a full cost-accounting system that would track the amount of time employees spend on each investigation and in training. 

• Develop mechanisms that will facilitate communications from staff-level employees to senior management, including consideration of contracting out a confidential employee survey to obtain employee feedback on management initiatives. 

To enhance the efficiency of the report development and recommendation closeout processes, we recommend that the Chairman take the following two actions: 

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

such things as using project managers or deputy investigators-in-charge in all 

modes, using incentives to encourage performance in report development, and 

examining the layers of review to find ways to streamline the process, such as 

eliminating some levels of review and using concurrent reviews as appropriate. 

• Improve the efficiency of the review process for changing the status of recommendations by computerizing the documentation and implementing concurrent reviews. 

To enhance the utilization of the academy and improve the ability to generate revenues that will cover academy costs, we recommend that the Chairman take the following three actions: 

• Develop a comprehensive marketing plan for the academy. The plan should consider such things as outreach to potential users, working with USDA and GSA 

33 

to market it as classroom and conference space, and conducting market research 

for additional curriculum development. If ethical and conflict-of-interest issues 

can be addressed, the plan should also consider options for allowing transportation manufacturers to conduct company-sponsored symposia and technical 

training at the academy facility, which would benefit NTSB investigators in 

keeping up with new technologies. In addition the plan should consider the feasibility of subleasing a portion of the academy space. 

• Develop core investigator curriculum for each mode and maximize the delivery 

of that training at the academy. 

• Conduct a study to determine the costs and feasibility of moving certain functions from headquarters to the academy facility in preparation for the renegotiation of the headquarters lease, which expires in 2011. 

Agency Comments 

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

Director concurred with our recommendations and provided clarifying comments 

and technical corrections, which we incorporated as appropriate. In addition, NTSB 

commented that the draft did not sufficiently distinguish improvements that have 

been made over the past year. We revised the testimony to more clearly distinguish 

those actions. 

Scope and Methodology 

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

management areas, we reviewed past GAO work on leading management practices 

in the areas of strategic planning, performance management, human capital management, financial management, and communications. We interviewed NTSB board 

members, senior officials, managers, investigators, and writer editors regarding 

their experience with those practices at NTSB, and their perceptions of the effectiveness of those practices. We also determined NTSB’s response to recommendations 

made by the DOTIG. We reviewed NTSB documents, including its strategic, staffing, and performance management plans; management advisory e-mail; and information regarding the current staffing levels; and employees’ training plans for 2006. 

To determine the extent to which NTSB is developing accident investigation reports and closing safety recommendations in an efficient manner, we interviewed 

NTSB investigators, writer editors, managers, and senior officials regarding the investigative process and their role in it. We randomly selected 15 of the 210 investigators and 8 writer editors evenly across the 4 modal offices. The views represent 

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

writer editors. We reviewed policy guidance on the investigative process and the 

level of current and past investigation activity. We examined data on recommendations acceptance rates and close-out status from NTSB’s recommendation database, 

and we determined that the data were sufficiently reliable for the objectives of this 

review. Additionally, we reviewed studies done by the RAND Corporation and Booz 

Allen Hamilton that examined NTSB’s investigation process and determined the extent to which the agency had implemented their recommendations. 

To determine the extent to which NTSB is generating sufficient revenues to cover 

costs at its academy, we reviewed financial data on NTSB’s academy, including the 

revenues and expenses for Fiscal Years 2004 and 2005. We reviewed the course curriculum of the academy, and compared it with classes offered by DOT’s Transportation Safety Institute, Embry Riddle, the University of Southern California, and 

the Southern California Safety Institute. We examined data on the student makeup of academy classes and analyzed data on the preparatory and teaching time used 

by NTSB investigators who taught at the academy. We interviewed NTSB investigators, writer editors, and managers and senior officials at DOT’s modal administrations regarding their current and planned use of the academy. Finally, we examined 

the lease for the academy to determine how NTSB may utilize the space. 

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

generally accepted government auditing standards. 

Contacts and Acknowledgments 

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

at (202) 512–2834 or by e-mail at dillinghamg@gao.gov. Individuals making key contributions to this testimony include Teresa Spisak, Colin Fallon, Eric Fielding, Tom 

Keightley, Maren McAvoy, Josh Ormond, and Jena Whitley. 

ENDNOTES 1Department of Transportation Act, P.L. 89–670, Oct. 15, 1966. 

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

34 

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

than as a result of specific accidents. 4 Not more than three members may be appointed from the same political party. 

At least three members are appointed on the basis of technical qualification, professional standing, and demonstrated knowledge in accident reconstruction, safety engineering, human factors, transportation safety, or transportation regulation. 5 49 U.S.C Sec. 1132(c). 

6Pub. L. No. 103–62. 

7GAO, Results Oriented Cultures: Creating a Clear Linkage between Individual 

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

14, 2003). 8GAO, A Model of Strategic Human Capital Management, GAO–02–373SP (Washington, D.C.: March. 15, 2002) and GAO, Human Capital: Key Principles for Effective Strategic Workforce Planning, GAO–04–39 (Washington, D.C.: December 11, 

2003). 9GAO, Executive Agency Management Diagnostic Survey (draft). 10 Each investigative team initially consists of at least one investigator-in-charge 

and other technical support investigator positions based on the complexity of the accident. 11 RAND Institute for Civil Justice, Safety in the Skies: Personnel and Parties in 

NTSB Accident Investigations (Santa Monica, CA.: 2000). 12GAO, Human Capital: A Guide for Assessing Strategic Training and Development Efforts in the Federal Government, GAO–04–546G (Washington, D.C.: March 

1, 2004). 13GAO, Executive Guide: Creating Value through World-class Financial Management, GAO/AIMD–00–134 (Washington, D.C.: April 2000). 14DOTIG, Audit of the Purchase Card Program, FI–2005–072 (Washington, D.C.: 

Aug. 23, 2005) and Report on Financial Management Practices and Internal Controls, FI–2003–004 (Washington, D.C.: Dec. 11, 2002). 15 Cost accounting involves the accumulation and analysis of financial and nonfinancial data, resulting in the allocation of costs to organizational pursuits such as 

performance goals, programs, activities, and outputs. Nonfinancial data measure the 

occurrences of activities and can include, for example, the number of hours worked. 16 RAND Institute for Civil Justice, 2000. 17GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers and 

Organizational Transformations, GAO–03–669 (Washington, D.C.: July 2, 2003). 18We randomly selected 15 investigators and 8 writer editors evenly across the 

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

The views represent the particular individuals and are not representative of all 

NTSB investigators and writer editors. 19The writer editors held a conference in February 2004. 20 Booz Allen Hamilton, NTSB Organizational Process and Efficiency Study 

(Washington, D.C.: Aug. 12, 2004). 21 In Fiscal Years 1999 and 2002, Booz Allen Hamilton found that the average 

time to complete a major investigation was 1.8 years; in Fiscal Years 2001 and 

2003, the average time was 1.9 years; in Fiscal Year 2000 the average was 2.4, 

mainly due to several lengthy aviation investigations that took over 4 years to complete. 22 Booz Allen Hamilton, however, found that the logic and rationale for changes 

made during the review process were not transparent. 23 49 U.S.C. Sec. 2135(d). NTSB pointed out that for those recommendations on 

the Most Wanted List, it specifically updates the list each November to ensure sufficient time for DOT to file its annual report to Congress. 24Senate Report 109–109 accompanying P.L. 109–115, the Transportation, Treasury, the Judiciary, Housing and Urban Development, and Related Agencies Appropriations Act of 2006. 25The revenue deficient for the 14 sessions totaled $54,279, and the revenue surplus for the two years totaled $307,203. 26 If the tuition fee is set by dividing the costs attributable to a course by the projected class size, the fee may not be competitive with fees charged by other institutions offering similar courses. In that case, the projected class size might not be attainable without lowering the tuition to a competitive level, with the result that fee 

revenues collected might not cover the attributable costs. 27 NTSB has a memorandum of understanding with GAO for the two agencies to 

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

with this agreement, only cost reimbursement after the first 14 days of providing 

space. 

35 

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

aircraft and other wreckage, eating and lounge areas, and office space for five employees who constitute NTSB’s Washington field office. 29We excluded federal holidays and the last week in December from our analysis. 

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

which courses used multiple classrooms. To account for that situation, we rounded 

up the percentage of space utilized. The use of multiple classrooms does not affect 

the information on the lack of using any classrooms for 21 weeks. 30The total number of students is the sum of the participants in all classes. Individuals who attended more than one class at the academy were, therefore, counted 

multiple times. 31 Individuals that attend more than one class are counted multiple times. 32These course sessions were Conducting Effective Technical Presentations; two 

sessions each of Media Training and Major Investigation Protocol and Processes; 

and a joint training class with the Federal Bureau of Investigation. 33Our review of course evaluations for Fiscal Years 2004 and 2005 indicated high 

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

for us to compare evaluations by NTSB students and non-NTSB students. 34 NTSB is considering contracting out more courses such as these. 

Senator BURNS. Dr. Dillingham, let’s just follow up with your recommendations and some of the things that you’ve taken note of. 

Now, your doing this management review, when will that study be 

complete? 

Dr. DILLINGHAM. We expect that the study will be complete before the end of the year, sir. 

Senator BURNS. And in recent years, the reports from the Office 

of Inspector General and a report done by the RAND Institute on 

NTSB, how has the NTSB responded to these reports? 

Dr. DILLINGHAM. The NTSB has taken action, particularly on the 

RAND report. In fact, I think it’s important to note that both the 

RAND report and a subsequent Booz Allen report were commissioned by the NTSB itself, recognizing that they needed this kind 

of information. 

Senator BURNS. Now, are there still some obstacles to be overcome before we undertake some of those, and I’d address this to 

both of you. What obstacles do we see in front of us that would prevent them from taking the steps as recommended from those reports? 

Dr. DILLINGHAM. Do you want to go first? 

Mr. ROSENKER. Doctor, thank you. Mr. Chairman, as it relates 

to the work that we’ve been doing with the GAO, I think it was 

a very constructive engagement and we are pleased we had the opportunity to work with them. Their recommendations are right on 

target. Much of what they’ve said, we’ve actually begun to try to 

accomplish. Areas such as the cost accounting system, something 

we find to be a valuable tool, and would like to continue to work 

on. We actually began last year with Quicktime in our payroll. 

We’ve actually had some examples where we’ve accomplished 

things like our ability to track specific costs. Most recently we did 

one at the request of the State Department. We did an investigation over in Sudan that we were going to be reimbursed for. We 

needed to be able to track every single dollar that had been involved in that investigation. We also did one for NASA a number 

of years ago on the Columbia Shuttle accident. 

So, we have the tool, if you will, in a basic way. But to do it 

across the board, which we would like to do, I believe, complies 

with the recommendation that the GAO has suggested, would cost 

36 

us several hundred thousand dollars, and unfortunately today, I 

don’t have that. But, I can assure you, it is an objective that we 

do wish to comply with. 

Senator BURNS. In other words, it’s a lack of funds more than 

anything else? 

Mr. ROSENKER. Yes, sir. 

Senator BURNS. You’re proposing, now I noticed in your statement that you’re proposing for 2007, 399 full-time equivalents but 

then in the out years 2008 and 2009, you’re requesting 475. Why 

the increase? 

Mr. ROSENKER. Sir, over the past five years, we’ve actually lost 

people. Approximately four years ago, we had something close to 

440 people. We are now down to 399, it’s a loss of 10 percent. These 

were critical skills, in some cases, that we lost. As we move into 

a more technologically advanced era, we need people to be able to 

understand and be able to do the kinds of critical investigations 

that will be necessary to prevent accidents that will occur, not 

could occur, but will occur. 

So, these positions we are trying to fill over the next two or three 

years will go a long way to helping us in that area. They will primarily be in the technological area where we don’t have these skills 

at this moment, additional fire people, we are looking for additional 

simulation people, we are looking for computer people, we are looking for avionics people, we are looking for composites people, and 

we’re actually looking for investigative bodies. We must have investigative bodies that will be sent to our regional offices if we are 

going to be able to keep up with the workload. 

Senator BURNS. How many regional offices do you maintain? 

Mr. ROSENKER. Ten, sir. 

Senator BURNS. Now, with new technologies, does that mean that 

an employee can be more efficient, or we’re just meeting different 

challenges now when we look at accidents as they occur? 

Mr. ROSENKER. Both of those, Mr. Chairman, we’re looking for 

new technological advances that we can employ in our investigations. But, at the same time, the kinds of equipment we’ll be looking at, aircraft that are fly-by-wire, aircraft that are made of composites. We need the technical skills in order to be able to accomplish and guarantee that we know exactly what happened to be 

able to prevent it from happening again. 

Senator BURNS. As you know, the IG is authorized to review the 

financial management and by the way, I think this committee is 

pleased that you’ve established a CFO for physical infrastructure. 

But, you know, sometimes we get penny-wise and dollar-dumb in 

the things that we do and we know we’ve got to react, how do we 

use new technologies to cut down the time on these reports and the 

recommendations made after the reports are known and studied? 

Mr. ROSENKER. We’re looking at that right now. We recognize 

that, in some cases, in many cases, it takes too long to bring a report to final and to bring it to the Board for public access. We’re 

taking a look. There are too many layers of oversight and examination. Now, we don’t want to, in any way shape or form, do a shortcut, we don’t want to lose the quality of the report. But, we believe 

that at the management level we can do better. Matter of fact, sir, 

in the past year, if you take a snapshot at where we are today as 

37 

opposed to where we were a year ago, we’ve improved productivity 

by 50 percent. We’ve gone from 14 reports to 21 reports to this 

point right now. 

Senator BURNS. Do we get burdened in just paperwork? 

Mr. ROSENKER. Part of it, Mr. Chairman, is paperwork, part of 

it, in fact, is a backlog, part of it is a resource management issue 

and some of it, sir, is really the complexity of the accident. Some 

accidents will take significantly longer. A good example of that is 

TWA Flight 800, the explosion of the TWA center wing fuel tank. 

Most recently a major accident, American 587, where the composite 

vertical stablizer was ripped off. These are very complex accidents 

and we must get them right, so they will take time, and again, we 

will not take shortcuts. 

Senator BURNS. Senator Lautenberg. 

Senator LAUTENBERG. Thanks Mr. Chairman, Mr. Rosenker, it 

takes awfully long to get reports finally issued, and GAO found it 

takes an average of three and a half years to finish a report. I 

mean, that really is a glitch that’s got to be tended to, and when 

you think about hearing there was an accident, and we often find 

the reason that these accidents take place fairly quickly, but yet 

the report drags on and drags on. What do you point to as the single delay factor that creates this, beside the continuing cry about 

more resources? And we understand that. 

Mr. ROSENKER. Well, I’m not going to blame that on resources 

alone, but I will dispute, and again this has been an excellent report, that the GAO has done. Unfortunately, I’m not sure they defined what that three and a half year accident would be. If we are 

talking about major accidents, and that’s what I just described as 

Flight 800, a TWA Flight 800, where in fact it took months. The 

FBI was doing a parallel investigation because we were not sure 

it was not terrorism. 

Another good example, as I say, is 587, which happened only 40 

days right after September 11th. Once again, we had to be correct. 

Those do take a great deal of time. They take science, they take 

a great deal of analysis, and, unfortunately, these are complex 

issues that we wish we could answer right away. But there are 

competing issues that go into something like this, we cannot make 

the wrong move, we must be right in these kinds of accidents. 

But, for the most part, in our general aviation accident reports, 

we’re really in a six month, six to nine month category. Many of 

our rail accidents, one that I was going to share with Senator Pryor 

this morning, one that happened in his state, we’re going to have 

before it’s a year old. We try to target these—— 

Senator LAUTENBERG. But we’re—— 

Mr. ROSENKER. Yes, sir—— 

Senator LAUTENBERG.—talking about averages. So it brings them 

all together. 

Mr. ROSENKER. Yes, sir, and I would believe, again, I hate to disagree because it has been a very good report, but the three and a 

half years I think is more in the major aviation type of actions. 

Senator LAUTENBERG. How about giving us a response to that, 

take a second look and put down your views on what’s taking place. 

Mr. ROSENKER. Yes, sir. 

Dr. DILLINGHAM. Senator Lautenberg. 

38 

Senator LAUTENBERG. Yes. 

Dr. DILLINGHAM. Could I please? 

Senator LAUTENBERG. Please, sure. 

Dr. DILLINGHAM. I’m glad you hate to disagree with us, but that’s 

not going to save you. 

[Laughter]. 

Dr. DILLINGHAM. Anyhow, it is, indeed, an average and I think 

it’s fair to say that major accidents like TWA 800 does skew it, because those are sort of outlyers. However, and it’s also true that 

NTSB will issue interim recommendations when they find something that is an immediate safety issue. However, in terms of 

where some of the length comes, that back-end process, within 

NTSB in terms of getting the recommendations out and processing 

the report, and all of those things are major contributors to the 

overall length of investigations. 

Senator LAUTENBERG. Mr. Rosenker, you advocate states actively 

take a proactive view of things and try to make the changes necessary to wherever they can, to make the roads, the rails, the rivers safer, the water body safer. Now, I wrote the law that raised 

the drinking age to 21 and we had enormous success with it, saving over 1,000 lives each and every year since 1984. But one of the 

things I found, that was interesting, Mr. Chairman, I was at a 

rodeo out west, in a state very familiar to you—— 

Senator BURNS. Don’t get to meddling now. 

Senator LAUTENBERG.—and the, I noticed a lot of young people 

drinking beer and so forth, and I asked the officer, who was very 

polite, very nice, and I enjoyed even seeing the kids riding the qtips and the whole business, I had never seen that before, q-tips 

being the sheep and little kids riding them, so I said to the police 

officer, do you know the drinking age? With respect, he replied, he 

said, yes sir, 21. So I said, do you think these young people are 21? 

He said, Mr., I do traffic. 

[Laughter]. 

Senator LAUTENBERG. And I tell that story, not to be so critical, 

but because I think there is probably some logic to his response. 

The fact of the matter is, I think if law enforcement were more 

rigid here, we’d save even more lives and it’s a constant battle between the kids who want to have fun and the society generally. 

Now, when you talk to states, do you have the opportunity to say, 

be more rigid on enforcing the law on 21, we could bring the rate 

down. We see that drunk driving or under the influence accidents 

continue to take a larger share of the fatalities that we have on the 

road. It’s a real menace and you lose, I think, 17,000 people a year 

as a result of driving under the influence. Can we do anything, do 

you think, to stimulate more attention to that mission? 

Mr. ROSENKER. Senator Lautenberg, first let me applaud the 

work that you’ve been doing. You’ve been a leader in this area, and 

we at the NTSB recognize that and are most greatful for the support you’ve provided in that area. Unfortunately, the drunk driving 

issue is a very difficult one, because in many cases it is the hardcore drunk driver who is sick. Enforcement clearly is an issue and 

we need more of that. Technology, we believe, can also play a role 

in that. But, as we go around, and our Members, the five Members 

of our Board, one of their major roles is to be advocates for safety 

39 

regulation, safety legislation, and we appear routinely before State 

Legislatures requesting the 21 age limit, requesting the graduated 

drivers licensing, requesting work to be done to improve our ability 

to bring down the numbers of drunk driving accidents and to improve the safety on our highways. Around 43,000 people every year, 

at least last year, and it’s close pretty much every year, die on our 

Nation’s highways. Three million are injured in seven million accidents. We need to do significantly more. It is the most dangerous 

mode of transportation, not only in the United States, but in the 

world. 

Senator LAUTENBERG. Mr. Rosenker, you spent some time working for the Motorcycle Lobby, did you at any time during that work 

oppose federal requirements for universal motorcycle helmet laws? 

Mr. ROSENKER. Sir, when I was representing the Motorcycle 

Safety Foundation, simultaneously I was representing the American Safety Helmet Council, so I thought I had an inside way of 

getting the helmets put onto riders. I am an advocate of that personally, I believe it is very important and its fool hardy to be in 

any way, shape, or form on a motorcycle or a bicycle without a helmet. 

Senator LAUTENBERG. Well, because we had a helmet law on the 

books. I was the author, and after about three or four years, a couple of my colleagues decided that that wasn’t the free spirit 

enough, and they had them taken off and in checking with our 

emergency clinics in New Jersey, found out that head and neck injuries, the primary cause of death or paralysis went up in reverse 

to the requirements for helmets. So, I’d like, I’m going to try again 

to get a helmet law in place and I just wondered whether you 

would have any opposition. 

Mr. ROSENKER. Not in the least, sir, and I applaud that effort 

and any way we can be helpful to you, sir, we will. 

Senator LAUTENBERG. Mr. Chairman, I thank you for holding 

this hearing, it’s very important and because of the time crush. 

Senator BURNS. Thank you very much, I thought you were going 

to tell some rodeo stories, we can go back in the back. 

Senator LAUTENBERG. You know, I had a good one, I had a rodeo 

experience. 

Senator BURNS. Did you? 

Senator LAUTENBERG. If you think it wasn’t hard getting up—— 

Senator BURNS. Getting up on that bull, you’re mistaken. 

[Laughter]. 

Senator BURNS.—I’ll tell you a little story about that, you 

know—— 

Senator LAUTENBERG. Alright. 

Senator BURNS. Every kid’s gotta try one and I, not being the exception, but you can also, if you try two, that’s a dead giveaway to 

your I.Q., too, if you try the second one. 

[Laughter]. 

Senator BURNS. I even tried three and that doesn’t say much. 

I’ve got a couple other questions, we’re voting now and we want 

to complete that, and I just appreciate you coming up on this abbreviated hearing this morning. We are going to be working very 

hard, and working with Senator Lautenberg to get this reauthorized, and I look forward to you being confirmed in your new posiVerDate Nov 24 2008 11:11 Aug 03, 2011 Jkt 067624 PO 00000 Frm 00043 Fmt 6633 Sfmt 6601 S:\GPO\DOCS\67624.TXT SCOM1 PsN: JACKIE
40 

tion at the NTSB, I think you’re going to be a good leader, and I 

appreciate the work of Dr. Dillingham and his work. He’s institutional, he doesn’t need any notes, he knows more about this outfit 

than they know about themselves, I would imagine, some that he 

can’t talk about. But in other words, the relationship is a good one 

and it makes the organization more efficient and with a due respect for each other and I appreciate that very much. So we will 

leave the record open for a couple of weeks and any questions you 

might get, you might respond again to the Committee and to the 

individual Senator, and I appreciate you coming early this morning. 

Dr. DILLINGHAM. Thank you, Mr. Chairman. 

Mr. ROSENKER. Thank you, Mr. Chairman and thank you, Senator Lautenberg. 

Senator BURNS. Yes, sir. 

[Whereupon at 9:46 a.m. the hearing was adjourned] 

(41) 

A P P E N D I X 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. INOUYE TO

GERALD L. DILLINGHAM

Question 1. In your testimony, you state that in the past two fiscal years the 

Academy has been operating, it has not been able to generate sufficient revenue in 

order to cover its operating costs. In your estimation, is there a way the Academy 

could maximize the use of the space in order to generate more revenue? 

Answer. Yes. As a first step to maximize the use of space and generate additional 

revenue, we have recommended that the National Transportation Safety Board 

(NTSB) develop a comprehensive business plan or marketing strategy for its training Academy, which is leased through 2021. During Fiscal Years 2004 and 2005, the 

Academy collected over $12,000 and $91,000 respectively, from sources other than 

course fees. However, our Office of General Counsel is investigating whether NTSB 

has the authority to retain the proceeds from any subleases of Academy property. 

Our preliminary review indicates that NTSB does not have special authority to do 

so. We do know the General Services Administration is generally required to turn 

over all proceeds from the sale of federal property to the Treasury as miscellaneous 

receipts under 40 U.S.C. Sec. 571. We are investigating whether this provision applies to NTSB. Another consideration is whether the retention of proceeds would be 

considered an improper augmentation of appropriations. Generally, federal agencies 

would need specific authority to be able to retain and use these funds. Although 

NTSB does have specific authority under 49 U.S.C. Sec. 1118(c) to impose and collect fees for services provided, such as course fees, we do not believe this authority 

extends to the subleasing of Academy property. We anticipate fully addressing this 

issue in our final report on the NTSB that is due out later this year. 

Nonetheless, other options to maximize the use of Academy space include the following: 

• Subletting additional unused space to other users. For example, during Fiscal 

Years 2004 and 2005, the Academy rented space to organizations such as the 

Society of Automotive Engineers, George Washington University, and the National Association of State Boating Law Administrators for meetings, conferences, and boat storage. NTSB should continue to pursue this option. 

• Marketing space to academic users. Certain space is already configured as 

classrooms, and the Academy is located on George Washington University’s suburban Virginia campus. 

• Possibly relocating some headquarters staff to the Virginia facility when the 

headquarters lease expires in 2011. NTSB is not precluded by its Academy lease 

or its lease for headquarters space in Washington, D.C., from relocating some 

headquarters staff to the Virginia facility. At this time, there is very little difference in the base cost of the Academy lease and the headquarters lease at 

L’Enfant Plaza. Specifically, the headquarters lease requires an additional expense of real estate taxes at about $3 per square foot since the lease is through 

a privately-owned business, while the Academy is leased through a nonprofit organization, which is exempt from those taxes. Upon renewal in 2011, the downtown lease could increase or decrease, but that is unknown. Furthermore, the 

costs of relocation could equal or exceed the savings that NTSB might realize 

by moving some staff to the Academy and renting less space in Washington, 

D.C. For example, the Academy is currently configured as classrooms and lecture halls so an immediate cost would be new construction to configure office 

space. Other costs could include computer and phone networks, relocating staff, 

moving furniture and laboratory and other equipment. We have recommended 

that NTSB conduct a study to determine the costs and feasibility of moving certain functions from headquarters to the Academy. 

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Question 2. In your opinion, what options does the NTSB have in order to attract 

more students to the Academy? 

Answer. The National Transportation Safety Board (NTSB) has options to attract 

more external and internal students to the Academy. In Fiscal Year 2005, NTSB 

had about 1,400 students, of whom about 86 percent came from outside NTSB. Options to attract more external students include the following: 

• Create unique courses and aggressively market them. Currently, the Academy 

provides training that is similar to training provided by other institutions. Officials from the Federal Railroad Administration, Federal Aviation Administration, and Pipeline and Hazardous Materials Safety Administration told us that 

their investigators do not attend NTSB training because the Department of 

Transportation’s Transportation Safety Institute provides similar training inhouse. If NTSB were to offer different courses, it could potentially attract and 

retain new students. A marketing study could help NTSB assess the demand 

for different types of courses. 

• List the availability of Academy training on the General Service’s Administration (GSA’s) website at www.gsa.gov/aircraftpolicy. At this site, GSA identifies 

training opportunities for personnel in the federal aviation community, such as 

‘‘annual aviation workshops’’ and ‘‘training for federal aviation.’’ Other training 

entities, including the Transportation Safety Institute, Embry Riddle Aeronautical University, and the Southern California Safety Institute, publicize 

their aviation training on this site. 

To attract more internal students, we have recommended that NTSB develop a 

core curriculum and add more classes that address the skills and competencies 

needed by its investigative staff. NTSB staff currently take most of their training 

outside the Academy, perhaps because the Academy courses do not cover the required subject matter. Attracting more internal students would not increase revenues for NTSB, but would lower its external training costs. According to our analysis, 97 percent of the NTSB staff training requests for Fiscal Year 2006 are for external courses costing over $924,000. The remaining 3 percent of training is scheduled to come from courses at the Academy. 

Other actions that NTSB could take to increase internal enrollment at the Academy include: 

• allowing transportation manufacturers to conduct company-sponsored symposiums and technical training at the Academy, which could help NTSB investigators keep up with new technologies and 

• offering more internal training on subjects such as management skills, retirement, and computers. 

Question 3. In your opinion, should overhead costs such as building lease, maintenance, building security, and personnel be built into the price they charge for their 

courses, in order for the Academy to begin to be self-sustaining? 

Answer. In our opinion, the National Transportation Safety Board (NTSB) should 

not build overhead costs into the price the Academy charges for its courses. Currently, NTSB determines tuition prices by estimating direct course costs (such as 

the costs for course materials, contracted instructors, and the instructors’ travel) 

and dividing that cost by the projected class size. The cost to lease Academy space 

alone is a fixed annual expense of about $2.5 million. If this annual fixed cost were 

divided among the students who now attend the Academy, class costs would dramatically increase and would be less competitive with fees charged by other institutions for similar courses unless the annual fixed cost was offset by revenue from 

a large influx of additional students. A large number of additional students may not 

be possible, since there are likely to be good reasons to keep class sizes relatively 

small. 

The NTSB Academy currently charges as much or more per course than the average cost per course charged by other safety institutions. For example, the cost of 

NTSB’s Aviation Accident Investigation course is $2,400 for 10 days of instruction. 

DOT’s Transportation Safety Institute’s 8 day course on aviation accident investigation currently costs $1,687. The Southern California Safety Institute’s similar 11 

day course ranges from $2,587 to $2,875 depending on the number of enrollees. Any 

additional charges for NTSB’s courses could reduce the Academy’s revenues by pricing the courses out of comparable range for other transportation safety training institutions. For example, if the Academy lease cost of $2.5 million was divided among 

the 36,160 student hours in Fiscal Year 2005, the additional cost per student hour 

would be $69. For NTSB’s 10 day Accident Investigation course, the additional cost 

43 

per student would be $5,520, increasing the cost to the student from $2,400 to nearly $8,000. 

Question 4. Do you think the funds that are currently going toward the Academy 

would be better used for investigations? 

Answer. If the funds currently going to the Academy were used for National 

Transportation Safety Board’s (NTSB) investigations and investigative staff, they 

would more directly support NTSB’s mission. We estimate that the net expenses of 

the Academy totaling $3,880,478 in Fiscal Year 2005 could fund over 25 additional 

investigative positions each year. However, since there is no cancellation clause in 

the Academy lease, NTSB would have to pay the remainder of the 20-year lease 

should it vacate the facility, which would amount to about $2.5 million annually 

through 2021. It is not unusual for a lease to lack a cancellation clause, because 

that allows for a lower monthly payment for the agency, but it also precludes NTSB 

from freeing up these funds for any other use during the life of the lease. 

Question 5. Do you think the NTSB’s practice of citing a ‘‘probable cause’’ precludes an in-depth evaluation of all relevant factors in an incident or accident; and 

that it creates an atmosphere of ‘‘establishing blame’’ rather than one of determining all means to prevent a future occurrence? Does the Board have the resources 

that would be necessary to increase the depth and scope of investigations? 

Answer. In our opinion, the National Transportation Safety Board’s (NTSB) practice of citing a ‘‘probable cause’’ does not preclude an in-depth evaluation of all relevant factors in an incident or accident. In analyzing NTSB accident reports, we 

found that the ‘‘probable cause’’ determination requires an in-depth analysis of all 

relevant factors during NTSB investigations. Moreover, because NTSB considers 

multiple factors in its analysis, the probable cause is often a comprehensive statement or paragraph, as opposed to a specific isolated cause. We found that NTSB’s 

process of fact finding and analysis during accident investigations does not in itself 

constitute or create an atmosphere of establishing blame. Instead, the process results in determining causes and making recommendations so that the chance of a 

similar accident occurring in the future is lessened. NTSB attempts to ensure that 

any factors that may have influenced an accident are discussed in the proper context in its analysis and final report. 

NTSB is able to provide the necessary depth and scope examining the incidents 

and accidents it does investigate. But with additional resources, it would have more 

flexibility to conduct additional investigations. Under the current staffing levels at 

NTSB, the agency makes a judgment as to whether to launch a full investigation, 

especially in areas other than aviation, which has a more defined legislative mandate. For the most part, NTSB managers make a determination of potential safety 

implications and consider the availability of resources, as well as the effect on ongoing investigations. Our ongoing work is evaluating NTSB’s accident investigation 

process as well as how decisions are made to launch investigations. 

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