[Senate Hearing 109-1145]
[From the U.S. Government Publishing Office]




                                                       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





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       SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                     TED STEVENS, Alaska, Chairman
JOHN McCAIN, Arizona                 DANIEL K. INOUYE, Hawaii, Co-
CONRAD BURNS, Montana                    Chairman
TRENT LOTT, Mississippi              JOHN D. ROCKFELLER IV, West 
KAY BAILEY HUTCHISON, Texas              Virginia
OLYMPIA J. SNOWE, Maine              JOHN F. KERRY, Massachusetts
GORDON H. SMITH, Oregon              BYRON L. DORGAN, North Dakota
JOHN ENSIGN, Nevada                  BARBARA BOXER, California
GEORGE ALLEN, Virginia               BILL NELSON, Florida
JOHN E. SUNUNU, New Hampshire        MARIA CANTWELL, Washington
JIM DeMINT, South Carolina           FRANK R. LAUTENBERG, New Jersey
DAVID VITTER, Louisiana              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 D. ROCKEFELLER IV, West 
JOHN McCAIN, Arizona                     Virginia, Ranking
TRENT LOTT, Mississippi              DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas          BYRON L. DORGAN, North Dakota
OLYMPIA J. SNOWE, Maine              BARBARA BOXER, California
GORDON H. SMITH, Oregon              MARIA CANTWELL, Washington
JOHN ENSIGN, Nevada                  FRANK R. LAUTENBERG, New Jersey
GEORGE ALLEN, Virginia               BILL NELSON, Florida
JOHN E. SUNUNU, New Hampshire        E. BENJAMIN NELSON, Nebraska
JIM DeMINT, South Carolina           MARK PRYOR, Arkansas


                            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


   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.
    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 Co-Chairmen 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 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 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 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 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 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 state-of-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, 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.
    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 highest-ranking 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.
    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 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 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 
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 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.
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.


    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.


    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.


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 short-and long-term planning, federal 
agencies risk delivering programs and services that may or may not meet 
the Nation's most critical needs. The Government Performance and 
Results Act of 1993 (GPRA) \6\ and guidance contained in the Office of 
Management and Budget's (OMB) Circular A-11, provide performance-based 
strategic planning guidelines. GPRA was intended to achieve several 
broad purposes, including improving federal program effectiveness, 
accountability, and service delivery, and enhancing Congressional 
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. 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.\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 recommendation by RAND 
Corporation, which evaluated NTSB's accident investigation process and 
workload in 1999.\11\ To help implement the realignment, senior 
managers told us that they would like to transition some existing 
administrative and support staff with appropriate background and 
training into investigator roles where possible. The draft plan set a 
target date of May 2006 to begin creating developmental opportunities 
for staff to transition to investigative roles and to develop reduction 
strategies for staff that fall outside the staffing plan.
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 resources.\13\ In recent years, NTSB has made significant 
progress in improving its financial management. In March 2001, NTSB 
hired a Chief Financial Officer who has emphasized the importance of 
sound financial management based on best practices. Similar to private-
sector companies, government agencies are required to report their 
financial condition in publicly-available financial statements. As a 
result of actions taken by NTSB, the agency received an unqualified or 
``clean'' opinion from independent auditors on its financial statements 
for the fiscal years ending September 30 for the years 2003, 2004, and 
2005. The audit report concluded that NTSB's financial statements 
presented fairly, in all material respects, the financial position, net 
cost, changes in net position, budgetary resources, and financing in 
conformity with generally accepted accounting principles for the three 
years. NTSB has also improved its purchasing and contracting activities 
after identifying problems in those areas in 1999. In 2001, DOT's 
Office of Inspector General (DOTIG) reviewed the agency's contracting 
and procurement activities and recommended that NTSB institute 
accountability and controls in its purchase card program as well as 
other purchasing activities. As a result 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 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 close-out processes. In terms of accomplishing its 
mission, since its inception, NTSB has investigated over 134,000 
transportation accidents. Eighty-two percent of its recommendations 
have been ``accepted,'' a term NTSB uses to include recommendations 
that recipients have said they would implement as well as those that 
have already been implemented. Figure 6 shows that highway 
recommendations have the highest acceptance rate and marine 
recommendations have the lowest.


NTSB 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.


    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.


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.
    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.
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 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 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.


    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 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, 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 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-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 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 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.
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 
make-up 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 
[email protected]. Individuals making key contributions to this 
testimony include Teresa Spisak, Colin Fallon, Eric Fielding, Tom 
Keightley, Maren McAvoy, Josh Ormond, and Jena Whitley.
ENDNOTES
    \1\ Department of Transportation Act, P.L. 89-670, Oct. 15, 1966.
    \2\ Independent Safety Board Act, P.L. 93-633, Title III, 1974.
    \3\ NTSB conducts safety studies as a result of identifying safety 
concerns rather than as a result of specific accidents.
    \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).
    \6\ Pub. L. No. 103-62.
    \7\ GAO, Results Oriented Cultures: Creating a Clear Linkage 
between Individual Performance and Organizational Success, GAO-03-488 
(Washington, D.C.: March 14, 2003).
    \8\ GAO, A Model of Strategic Human Capital Management, GAO-02-
373SP (Washington, D.C.: March. 15, 2002) and GAO, Human Capital: Key 
Principles for Effective Strategic Workforce Planning, GAO-04-39 
(Washington, D.C.: December 11, 2003).
    \9\ GAO, Executive Agency Management Diagnostic Survey (draft).
    \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).
    \12\ GAO, Human Capital: A Guide for Assessing Strategic Training 
and Development Efforts in the Federal Government, GAO-04-546G 
(Washington, D.C.: March 1, 2004).
    \13\ GAO, Executive Guide: Creating Value through World-class 
Financial Management, GAO/AIMD-00-134 (Washington, D.C.: April 2000).
    \14\ DOTIG, 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.
    \17\ GAO, Results-Oriented Cultures: Implementation Steps to Assist 
Mergers and Organizational Transformations, GAO-03-669 (Washington, 
D.C.: July 2, 2003).
    \18\ We 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.
    \19\ The 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.
    \24\ Senate Report 109-109 accompanying P.L. 109-115, the 
Transportation, Treasury, the Judiciary, Housing and Urban Development, 
and Related Agencies Appropriations Act of 2006.
    \25\ The 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.
    \28\ The 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.
    \29\ We 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.
    \30\ The 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.
    \32\ These 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.
    \33\ Our 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 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 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.
    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 q-tips 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 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 position 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]
                            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.

    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 in-
        house. 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 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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