National Transportation Safety Board: Preliminary Observations on the Value of Comprehensive Planning, and Greater Use of Leading Practices and the Training Academy
Published: 2006-05-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The National Transportation Safety Board (NTSB) is a relatively small agency that plays a vital role in transportation safety and has a worldwide reputation for investigating accidents. With a staff of about 400 and a budget of $76.7 million in fiscal year 2006, NTSB investigates all civil aviation accidents in the United States, and significant accidents in railroad, highway, marine, and pipeline; and issues safety recommendations to address issues identified during accident investigations. To support its mission, NTSB built a training academy, which opened in 2003 and provides training to NTSB investigators and others. It is important that NTSB use its resources efficiently to carry out its mission and maintain its preeminence. This testimony, based on ongoing work for this committee, addresses the extent to which NTSB follows leading practices in selected management areas, addresses challenges in completing accident investigations and closing safety recommendations, and generates sufficient revenues to cover costs at its academy.
section_title: What GAO Found
paragraphs: NTSB has recently made progress in following leading management practices, but overall has a mixed record. For example, NTSB has improved its financial management by hiring a Chief Financial Officer and putting controls on its purchasing activities, which should address past problems with unapproved purchases. However, NTSB lacks a full cost accounting system, which would inform managers of the resources spent on individual investigations and provide data to balance office workload. NTSB has also begun to develop a performance management system that should eventually link each individual's performance to the agency's strategic goals and objectives. However, the performance management system will not be fully functional until NTSB has developed a strategic plan with results-oriented goals and objectives and specific strategies for achieving them, which are lacking in the current strategic plan. Other areas, such as human capital and communications, partially follow leading practices. While NTSB is accomplishing its accident investigation mission, it faces challenges that affect the efficiency of the report production and recommendation close out processes. NTSB routinely takes longer than 2 years to complete major investigations. Several factors may affect the length of report production, including several revisions of draft reports through multiple layers of the organization. In addition, the processes for federal transportation agencies to implement NTSB's safety recommendations and for NTSB to change the status of recommendations are lengthy, paper-based, and labor intensive. While Department of Transportation officials have been working with NTSB to find acceptable means of implementing its recommendations, they cite the lengthy rule-making process as a challenge to speedy implementation. For fiscal years 2004 and 2005, NTSB's academy did not generate sufficient revenues to cover the costs of providing training. As a result, those portions of the academy's costs that were not covered by the revenues from tuition and other sources--approximately $6.3 million in fiscal year 2004 and $3.9 million in fiscal year 2005--were offset by general appropriations to the agency. While NTSB has taken action to generate revenue from other sources, such as renting academy space for conferences, it does not have a marketing plan that seeks to optimize opportunities for additional revenues at the academy.

section_title: Letter
paragraphs: We are pleased to be here today to discuss the reauthorization of the  National Transportation Safety Board (NTSB). NTSB is a relatively small  agency that plays a vital role in transportation safety. With a staff of about 400 and a budget of $76.7 million in fiscal year 2006, NTSB is charged with investigating every civil aviation accident in the United States and  significant accidents in the other modes—railroad, highway, marine, and  pipeline—,determining the probable cause of these accidents and issuing  recommendations to address safety issues identified during accident investigations. NTSB has gained a worldwide reputation as a preeminent agency in conducting transportation accident investigations. Since 1967, it has issued 1,340 major accident investigation reports, over 130,000 brief  accident reports, and made over 12,000 safety recommendations. To  support its mission, NTSB built a training academy that opened in 2003  and provides training to NTSB investigators and other transportation  safety professionals, including those from foreign countries. It is critical  that the agency uses its resources in an efficient manner to carry out its  safety mission and maintain its preeminent position. For this reason, you  asked us to conduct a comprehensive review of NTSB’s management functions such as strategic planning, human capital management, and  mission-critical investigation activities. My testimony today is based on  our ongoing work for you, and it addresses the extent to which NTSB is  (1) following leading practices in selected management areas, (2)  addressing challenges in completing accident investigations and closing  safety recommendations, and (3) generating sufficient revenues to cover costs at its academy. We will be reporting additional results of our ongoing  work to the committee later this year.
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 buy-in on report messages and holding modal directors accountable for specific issuance dates. We  also identified practices in certain offices, such as the use of a project  manager or deputy investigator-in-charge to handle report production,  which may improve the efficiency of report development if used by all modal offices as they all are similar in what they do. The processes for  implementing NTSB’s safety recommendations, and for NTSB to change the status of recommendations are also lengthy and labor intensive. As a  result, unsafe conditions may continue to exist until federal transportation agencies, and ultimately, transportation industries, fully implement the  recommendations, and the extended period it takes to change the status of recommendations ties up NTSB’s scarce resources. As of May 2006, 305 of the 852 open recommendations have been in open status for 5 years or  more. While Department of Transportation (DOT) officials have been  working with NTSB to find acceptable means of implementing its  recommendations, they cite the lengthy rule-making process as a challenge to speedy implementation. In addition, the process that NTSB uses to  change the status of safety recommendations is paper-based, labor intensive, and relies on a series of sequential reviews that can take months  to complete. As a result, resources within NTSB are inefficiently used and  DOT agency officials told us they remain unaware whether their response  has been accepted or not accepted.
For fiscal years 2004 and 2005, NTSB’s academy did not generate sufficient revenues to cover the costs of providing training. As a result, those  portions of the academy’s costs that were not covered by the revenues  from tuition and other sources—approximately $6.3 million in fiscal year  2004 and $3.9 million in fiscal year 2005—were offset by general appropriations to the agency. Although there is no statutory requirement  that revenues from NTSB’s academy generate sufficient revenues to cover the costs, NTSB was encouraged in the Senate report accompanying the Fiscal Year 2006 DOT Appropriations Act to be more aggressive in  imposing and collecting fees to cover the costs. While NTSB has taken  action to generate revenue from other sources, such as renting academy space for conferences, it does not have a business plan that seeks to  optimize opportunities for additional revenues at the academy.  Additionally, NTSB is missing opportunities to find other uses for academy space. For example, during fiscal year 2005, less than 10 percent of the  total classroom space was used. About 14 percent of the academy students  in fiscal year 2005 were NTSB employees. However, in 2006, NTSB employees are scheduled to take 97 percent of their requested training  from sources other than the academy, such as DOT’s Transportation  Safety Institute. The academy is not utilized more by NTSB staff, in part,  because the agency has not developed a core curriculum for its staff,  which it could then offer at the academy. Furthermore, many academy  courses are similar to those taught elsewhere, which may affect the  agency’s ability to attract non-NTSB students.
subsections: section_title: Background
paragraphs: NTSB was established in 1966 as an independent government agency located within the newly formed DOT. In 1974, Congress made NTSB  completely separate from DOT. 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 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.
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. 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.
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. 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.
section_title: NTSB Has Made Recent Progress in Following Leading Management Practices, But Overall Record Remains Mixed
paragraphs: 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.
subsections: section_title: NTSB’s Strategic Plan Lacks Certain Performance-Based Elements and Performance Management Plans Closely Follow Leading Practices but are not Fully Functional
paragraphs: The Congress and the President have encouraged better management of  federal agencies by means such as results-oriented strategic planning, but NTSB’s strategic plan generally does not follow performance-based  practices. Without effective short- and long-term planning, federal agencies risk delivering programs and services that may or may not meet  the nation’s most critical needs. The Government Performance and Results Act of 1993 (GPRA) and guidance contained in the Office of Management and Budget’s (OMB) Circular A-11, provide performance-based strategic  planning guidelines. GPRA was intended to achieve several broad purposes, including improving federal program effectiveness, accountability, and service delivery, and enhancing congressional decision making by providing more objective information on program performance.  GPRA requires federal agencies to develop strategic plans in which they  define their missions, establish results-oriented goals, and identify the  strategies that will be needed to achieve those goals. For instance, GPRA  requires strategic plan updates at least every 3 years, and requires that  agencies set objectives and goals that are specific outcomes that the  organization wishes to accomplish (called outcome-related objectives).
To its credit, in December 2005, NTSB issued a strategic plan for the years 2006 through 2010, which was the first time the agency had a strategic plan in 6 years. In developing that plan, senior agency officials told us that they modeled their plan on examples from other federal agencies with similar  structure and mission, such as the Federal Communications Commission. We compared NTSB’s strategic plan to selected elements required by  GPRA. (See fig. 5.)
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 development of the strategic plan. Some  current and past board members additionally stated that they believed that their involvement would be beneficial in providing a strategic vision for  the agency. NTSB’s senior management told us they expect to revise the  strategic plan in the near future and contacted us regarding assistance to  develop a more comprehensive, results-oriented plan as part of this study.
NTSB has begun to develop a performance management system that  should eventually link each individual’s performance throughout the  agency to the agency’s strategic goals and objectives. We have reported  that performance management systems are crucial for agencies because if developed properly they allow employees to make meaningful contributions that directly contribute to agency goals. 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.
section_title: NTSB’s Staffing Plan Is a Step in the Right Direction, but the Organizational Structure Has Not Been Reviewed
paragraphs: 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.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. 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. The modal office directors’ request for staff resulted in a total agency allotment of 455 full time  equivalents (FTEs) plus 20 co-op positions. The Managing Director reduced this number to 404, which corresponds to NTSB’s current funding  level of 395, allowing for attrition and turnover. The Managing Director’s  allocation resulted in a proposed increase of 21 investigators agencywide  and a proposed reduction of certain staff positions to accommodate the  increase in investigators. This increase in investigative staff is consistent with a recommendation by RAND Corporation, which evaluated NTSB’s  accident investigation process and workload in 1999. 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.
section_title: NTSB Lacks a Strategic Approach to Training Staff
paragraphs: 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. 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.
section_title: Financial Management Is Improved, but NTSB Lacks a Full Cost Accounting System
paragraphs: Sound financial management is crucial for responsible stewardship of  federal resources. 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, 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 of all agency activities. 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.
section_title: Communications from Senior Management to Staff have Increased and Communications Among Offices is Generally In Place, but Upwards Communications Mechanisms Are Lacking
paragraphs: 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. In response to  issues raised by NTSB employees in a governmentwide survey conducted by OPM in 2004, NTSB’s senior management made changes to improve the way it is communicating information to staff. For example, the Managing Director periodically sends “management advisory” e-mail to all staff that share information such as policy changes or new developments at the  agency. However, we found no formal processes that encouraged two-way  communication, such as town hall meetings, regular staff meetings, or  anonymous employee surveys; or incorporated employee feedback into  policy-making.
The 23 investigators and writer editors with whom we spoke had mixed  views on the effectiveness of communications within the agency. 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. 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.
section_title: NTSB Is Accomplishing Its Accident Investigation Mission, but Opportunities Exist to Gain Efficiencies
paragraphs: While NTSB is accomplishing its accident investigation mission, it faces challenges that affect the efficiency of the report production and recommendation close-out processes. In terms of accomplishing its  mission, since its inception, NTSB has investigated over 134,000 transportation accidents. Eighty-two percent of its recommendations have been “accepted,” a term NTSB uses to include recommendations that  recipients have said they would implement as well as those that have already been implemented. Figure 6 shows that highway recommendations have the highest acceptance rate and marine recommendations have the lowest.
subsections: section_title: NTSB Investigations Are Often Lengthy, in Part Because Investigators Must Launch New Investigations Before Completing Ongoing Investigations
paragraphs: 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 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. 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.
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.
section_title: Writing and Report Production Is a Bottleneck in the Process
paragraphs: 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. 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.
section_title: Certain Agency Practices May Help Shorten Report Development
paragraphs: NTSB has recently taken several actions that, along with potentially better practices in one modal office, may help shorten report development time.  First, in response to a recommendation by Booz Allen Hamilton to gain  management’s buy-in to the report message before writing the report and  thereby reduce the number of review iterations, NTSB management has  reemphasized its policy for report development meetings. NTSB has a  long-standing order that calls for holding message development meetings  with internal stakeholders who will be reviewing the report prior to report  writing. According to a senior NTSB official, however, the agency had stopped following that policy before Booz Allen Hamilton conducted its  study in 2004. The official further stated that subsequent to that recommendation, NTSB’s managing director sent a memorandum  reminding staff to follow the policy. While NTSB has no data on whether  the message development meetings are actually taking place, officials told us that the managing director’s recent emphasis on these meetings was  resulting in more of them occurring than in previous years.
Second, since the spring of 2005, NTSB has initiated production meetings  with senior management with the goal of reducing the duration of  investigations. These meetings occur every 2 weeks and focus on report  development and production. NTSB modal directors are held accountable for a specific issuance date within a six month planning window prior to  issuing a report. During the biweekly meetings, the directors discuss with  NTSB’s Managing Director and senior executives their progress and  commitments to complete the investigations. The meetings result in a  production schedule that is available for subsequent review. The modal  directors stated that they believe the new system is effective in reducing  the duration of investigations; however because these meetings began so  recently, it is too early to evaluate their effectiveness.
Third, the highway office—which has the swiftest rate of accident investigation completion—uses a concept called a “project manager,” who serves as a supervisory writer editor and interface between the 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-in- charge 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.
section_title: Safety Recommendations Close-out Process Is Time Consuming for Several Reasons
paragraphs: 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 rule-making process,  which includes budgeting and allocating resources to develop the  proposed regulation, drafting and receiving comments on proposed rules,  and waiting for the industry’s subsequent response to implement the final  rule. For example, TWA flight 800 crashed off Long Island in July 1996; NTSB issued safety recommendations pertaining to explosive fuel tanks in  December 1996. NTSB adopted the accident report with further  recommendations to FAA to reduce flammable vapors in aircraft fuel  tanks in 2000; FAA issued a notice of proposed rule to address this  recommendation in November 2005; the comment period for the notice ended on March 23, 2006. Thus, 10 years after the crash, the final rule has not been issued. Federal transportation officials also said the failure to  satisfy a cost-benefit analysis might impede the implementation of NTSB  recommendations. Although NTSB is required to only consider the safety  implications of its recommendations and not consider the cost factors, if a  proposed regulation is not cost beneficial, it cannot be approved by OMB.
Federal officials with whom we spoke at DOT, which receives the bulk of NTSB recommendations, indicated that they have been working with  NTSB to find acceptable means of implementing recommendations. The  process—recently called Safety With a Team—is designed for NTSB and  federal agencies to work in cooperation to address open recommendations and implement needed safety improvements. NTSB and DOT officials told us that this process contributed to the closing of many recommendations. However, the process is not used with the Coast Guard, which has the  lowest rate—74 percent—for accepting NTSB recommendations among  the modes, as mentioned previously. According to a Coast Guard official  we spoke with, the Coast Guard believes that it has an acceptable rate for  closing NTSB recommendations and that it does not intend to act on  recommendations that it deemed unnecessary.
NTSB recognizes that open recommendations can have serious safety  implications for the transportation industry. To spur implementation, the agency also publishes a “most wanted” list of what it considers the most  serious safety concerns. For example, in 2000 NTSB added to its most  wanted list the need to improve the safety of motor carrier operations.  NTSB recommended that FMCSA prevent motor carriers from operating if they put vehicles with mechanical problems on the road or unqualified drivers behind the wheel. As recently as May 2006, NTSB issued an  additional recommendation that FMCSA “establish a program to verify  that motor carriers have ceased operations after the effective date of  revocation of operating authority.”
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.
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 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.
section_title: NTSB’s Academy Does Not Generate Sufficient Revenues to Cover Costs and Is Not Fully Utilized
paragraphs: 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. 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.
subsections: section_title: Academy Costs Have Exceeded Revenues
paragraphs: 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.
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.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. 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.While NTSB has taken action to generate revenue  from other sources, it does not have a business plan or marketing strategy that seeks to optimize opportunities for additional revenues. According to the academy’s deputy manager, NTSB plans to develop a business plan.  The agency, however, has no timeframes for doing so.
Our analysis of the academy lease indicates that NTSB has the flexibility to use the facility in other ways to generate revenues or potentially reduce costs. For example, the lease does not preclude NTSB from subletting unused space to other users. Since certain space is already configured as  classrooms and the academy is located in an academic setting on George  Washington University’s suburban Virginia campus, it may be possible to  market space to academic users. Furthermore, NTSB is not precluded by its academy lease or its lease for headquarters space in Washington, D.C.,  from relocating some headquarters staff to the Virginia facility. The lease 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.
section_title: Academy Classrooms Are Significantly Underutilized
paragraphs: NTSB has not maximized the use of the facility, which could generate additional revenues that may help cover costs. We estimate that, overall, less than 10 percent of the total classroom space was used during fiscal  year 2005. 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 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 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. While increasing the use of  the academy by NTSB staff would reduce the costs of sending them to  external training, it is important that NTSB not reduce the number of  external, paying students in the process.
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; 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. However, no  milestones or specific plans have been established for that effort.
Although most students at the academy are from outside NTSB, several  factors can affect the agency’s ability to attract additional outside  students. First, the lack of a business or marketing plan may be affecting NTSB’s ability to fully utilize the academy. Second, academy training is  similar to training provided by other institutions. FRA, FAA, and PHMSA  officials told us that their investigators do not attend NTSB training  because similar training is provided in-house by DOT’s Transportation  Safety Institute. For example, an FAA investigator told us that new  investigators take a basic accident investigation course at the  Transportation Safety Institute and subsequently take mid-career 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.
section_title: Additional Issues Concerning the Academy
paragraphs: 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-Deficiency Act because it did not obtain budget authority for the  net present value of the entire 20-year lease obligation at the time the lease agreement was signed in 2001. NTSB realized the error in 2003 and  reported its noncompliance to Congress and the President. NTSB has  proposed in the President’s fiscal year 2007 budget to remedy this antideficiency act violation by inserting an amendment in their fiscal year  2007 appropriation that would allow NTSB to fund this obligation from  their salaries and expense account through fiscal year 2020.
section_title: Conclusions
paragraphs: 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.
section_title: Recommendations for Executive Action
paragraphs: 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 close-out processes, we recommend that the Chairman take the following two actions:  Identify better practices in the agency and apply them to all modes. Consider such things as using project managers or deputy investigators-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 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.
section_title: Agency Comments
paragraphs: 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.
section_title: Scope and Methodology
paragraphs: To determine the extent to which NTSB is following leading practices in  selected management areas, we reviewed past GAO work on leading management practices in the areas of strategic planning, performance management, human capital management, financial management, and  communications. We interviewed NSTB board members, senior officials,  managers, investigators, and writer editors regarding their experience with those practices at NTSB, and their perceptions of the effectiveness of  those practices. We also determined NTSB’s response to  recommendations made by the DOTIG. We reviewed NTSB documents,  including its strategic, staffing, and performance management plans;  management advisory e-mail; and information regarding the current staffing levels; and employees’ training plans for 2006.
To determine the extent to which NTSB is developing accident investigation reports and closing safety recommendations in an efficient manner, we interviewed NTSB investigators, writer editors, managers, and senior officials regarding the investigative process and their role in it. We randomly selected 15 of the 210 investigators and 8 writer editors evenly  across the 4 modal offices. The views represent the particular individuals and are not representative of all NTSB investigators and writer editors. We  reviewed policy guidance on the investigative process and the level of  current and past investigation activity. We examined data on  recommendations acceptance rates and close-out status from NTSB’s recommendation database, and we determined that the data were sufficiently reliable for the objectives of this review. Additionally, we  reviewed studies done by the Rand Corporation and Booz Allen Hamilton  that examined NTSB’s investigation process and determined the extent to 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.
section_title: Contacts and Acknowledgments
paragraphs: 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.
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