    National Transportation Safety Board: Progress Made, Yet
    Management Practices, Investigation Priorities, and Training
    Center Use Should Be Improved (22-NOV-06, GAO-07-118).

    The National Transportation Safety Board (NTSB) plays a vital
    role in advancing transportation safety by investigating
    accidents, determining their causes, and issuing safety
    recommendations. To support its mission, NTSB's training center,
    which opened in 2003, provides training to NTSB investigators and
    others. It is important that NTSB use its resources efficiently
    to carry out its mission. GAO was asked to examine the extent to
    which NTSB follows leading management practices, how NTSB carries
    out its transportation safety function, and the extent to which
    NTSB's training center is cost-effective, including potential
    options for improving the center's cost-effectiveness. GAO
    reviewed NTSB documents and data concerning management practices
    and accident investigations, interviewed relevant NTSB and other
    federal officials, and evaluated NTSB's management practices
    based on leading practices identified in prior work.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-118
        ACCNO:   A63645
      TITLE:     National Transportation Safety Board: Progress Made, Yet
    Management Practices, Investigation Priorities, and Training
    Center Use Should Be Improved
         DATE:   11/22/2006
      SUBJECT:   Cost analysis
    	     Employee training
    	     Human capital management
    	     Information technology
    	     Internal controls
    	     Performance management
    	     Procurement practices
    	     Program management
    	     Risk assessment
    	     Safety regulation
    	     Strategic planning
    	     Training utilization
    	     Transportation
    	     Transportation safety
    	     Agency missions
    	     Anti-deficiency act violations

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    GAO-07-118

         * [1]Results in Brief
         * [2]Background

              * [3]NTSB's Organization and Resources
              * [4]Investigative Process
              * [5]Leading Management Practices

         * [6]NTSB Has Made Recent Progress in Following Leading Managemen

              * [7]NTSB's Strategic Plan Lacks Certain Performance-Based Elemen
              * [8]NTSB Is Partially Following Leading Human Capital Practices

                   * [9]NTSB's Staffing Plan Is a Step in the Right Direction for
                     Wo
                   * [10]Performance Management Plans Closely Follow Leading
                     Practice
                   * [11]NTSB Lacks a Strategic Approach to Training Staff
                   * [12]NTSB Uses Flexibilities to Recruit and Retain Staff, but
                     Str
                   * [13]NTSB Is Not Following Most Diversity Management Leading
                     Prac

              * [14]Communications from Senior Management to Staff Have Increase
              * [15]Acquisition Management Has Made Significant Progress in Rece
              * [16]NTSB Follows Certain Leading Practices in Financial Manageme
              * [17]NTSB Is Making Progress in IT Management but Still Lacks Key
              * [18]NTSB Lacks a Knowledge Management Program

         * [19]NTSB Carries Out Its Transportation Safety Function by Inves

              * [20]NTSB's Use of Risk-Based Criteria to Select Accidents to Inv
              * [21]NTSB Has Taken Steps to Reduce the Potential Negative Conseq
              * [22]External Sources Provide Essential Services during Accident
              * [23]NTSB May Also Conduct Public Hearings During Investigations,
              * [24]Most NTSB Recommendations Are Accepted, but Some Recommendat
              * [25]NTSB Takes Proactive Steps Outside of Specific Accident Inve

         * [26]NTSB's Training Center Is Not Cost-Effective; Options Could

              * [27]Training Center's Revenues and Avoided Costs Do Not Cover Tr
              * [28]Training Center Revenues Are Affected by Low Utilization, Av
              * [29]Several Options Could Increase Revenues or Reduce Costs

         * [30]Conclusions
         * [31]Recommendations for Executive Action
         * [32]Agency Comments
         * [33]Appendix I: Scope and Methodology
         * [34]Appendix II: Prior GAO Recommendations to NTSB
         * [35]Appendix III: Additional Analysis of NTSB Safety Recommendat
         * [36]Appendix IV: Comments from the National Transportation Safet
         * [37]Appendix V: GAO Contact and Staff Acknowledgments

              * [38]GAO Contact
              * [39]Staff Acknowledgments

         * [40]Related GAO Products

              * [41]Order by Mail or Phone

    Report to Congressional Requesters

    United States Government Accountability Office

    GAO

    November 2006

    NATIONAL TRANSPORTATION SAFETY BOARD

    Progress Made, Yet Management Practices, Investigation Priorities, and
    Training Center Use Should Be Improved

    GAO-07-118

    Contents

    Letter 1

    Results in Brief 3
    Background 6
    NTSB Has Made Recent Progress in Following Leading Management Practices,
    but Overall Record Remains Mixed 15
    NTSB Carries Out Its Transportation Safety Function by Investigating
    Accidents, Issuing Recommendations, and Taking Proactive Steps Outside of
    Specific Accidents 32
    NTSB's Training Center Is Not Cost-Effective; Options Could Increase
    Cost-Effectiveness, but Vacating Space May Be Least-Cost Strategy 45
    Conclusions 57
    Recommendations for Executive Action 58
    Agency Comments 59
    Appendix I Scope and Methodology 60
    Appendix II Prior GAO Recommendations to NTSB 64
    Appendix III Additional Analysis of NTSB Safety Recommendations Data 66
    Appendix IV Comments from the National Transportation Safety Board 74
    Appendix V GAO Contact and Staff Acknowledgments 76
    Related GAO Products 77

    Tables

    Table 1: Number of Accident Investigations Completed by NTSB by Mode,
    Fiscal Years 2002-2005 9
    Table 2: NTSB Training Center and Headquarters Capital Assets, as of
    September 2006 12
    Table 3: Number of Public Hearings by Mode, Calendar Years 1997-2006 40
    Table 4: Number of Safety Studies by Mode, Calendar Years 2000-2005 44
    Table 5: Direct Expenses and Revenues for the NTSB Training Center, Fiscal
    Years 2004 and 2005 (unaudited) 46
    Table 6: Entities Interviewed by GAO 61
    Table 7: Safety Recommendation Data Fields Analyzed 62
    Table 8: Number and Percentage of NTSB Safety Recommendations with Closed
    Acceptable, Closed Unacceptable, and Open Status by Mode, for
    Recommendations Issued Calendar Years 1996-2005 72

    Figures

    Figure 1: Key Laws, Regulations, and NTSB Policies for Investigations by
    Mode 8
    Figure 2: NTSB's Organization 10
    Figure 3: Number of NTSB Investigators and Technical Staff, Fiscal Years
    2000-2007 11
    Figure 4: Components of an NTSB Investigation and Recommendation Closeout
    13
    Figure 5: Extent to Which NTSB Follows Leading Practices in Selected
    Management Areas 16
    Figure 6: Extent to Which NTSB's Strategic Plan Follows GPRA Elements 17
    Figure 7: Extent to Which NTSB Follows Leading Practices in Selected Human
    Capital Management Areas 18
    Figure 8: Leading Practices in Diversity Management 23
    Figure 9: Legislative, Regulatory, and Other Criteria for Identifying
    Accidents to Investigate, by Mode 33
    Figure 10: Average Duration of Accident Investigations for Which
    Recommendations were Issued, Calendar Years 1996-2006 37
    Figure 11: Acceptance Rate by Mode, Calendar Years 1996-2006 41
    Figure 12: Percentage and Number of Open Recommendations with Unacceptable
    Agency Action Issued During Calendar Years 1996-2006 42
    Figure 13: Number of NTSB and Non-NTSB Students, Fiscal Years 2004-2006 48
    Figure 14: Utilization of Training Center Classrooms by Classes and Other
    Events, Fiscal Year 2006 51
    Figure 15: Number of Recommendations by Mode of Transportation and by Year
    Issued, Calendar Years 1996-2006 66
    Figure 16: Number of Accident Investigations with Safety Recommendations,
    Calendar Years 1996-2006 67
    Figure 17: Number of Investigations Completed by Mode, Calendar Years
    1996-2006 68
    Figure 18: Average Investigation Duration by Mode, Calendar Years
    1996-2006 70
    Figure 19: Percentage of Safety Recommendations Open for at Least 5 Years,
    by Mode 73

    Abbreviations

    CFO Chief Financial Officer CIO Chief Information Officer CMMI Capability
    Maturity Model(R) Integration DOT Department of Transportation DOT IG
    Department of Transportation's Inspector General FAA Federal Aviation
    Administration FHWA Federal Highway Administration FMCSA Federal Motor
    Carrier Safety Administration FRA Federal Railroad Administration FTA
    Federal Transit Administration GSA General Services Administration GPRA
    Government Performance and Results Act of 1993 IDEAS Interior Department
    Electronic Acquisition System IT information technology NHTSA National
    Highway Traffic Safety Administration NTSB National Transportation Safety
    Board OPM Office of Personnel Management PHMSA Pipeline and Hazardous
    Materials Safety Administration TSI Transportation Safety Institute

    This is a work of the U.S. government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
    its entirety without further permission from GAO. However, because this
    work may contain copyrighted images or other material, permission from the
    copyright holder may be necessary if you wish to reproduce this material
    separately.

    United States Government Accountability Office

    Washington, DC 20548

    November 22, 2006 November 22, 2006

    The Honorable Ted Stevens Chairman Committee on Commerce, Science, and
    Transportation United States Senate The Honorable Ted Stevens Chairman
    Committee on Commerce, Science, and Transportation United States Senate

    The Honorable Daniel Inouye Co-Chairman Committee on Commerce, Science,
    and Transportation United States Senate The Honorable Daniel Inouye
    Co-Chairman Committee on Commerce, Science, and Transportation United
    States Senate

    The Honorable James L. Oberstar Ranking Democratic Member Committee on
    Transportation and Infrastructure House of Representatives The Honorable
    James L. Oberstar Ranking Democratic Member Committee on Transportation
    and Infrastructure House of Representatives

    With a staff of 386 and a budget of $76.7 million in fiscal year 2006, the
    National Transportation Safety Board (NTSB) is a relatively small agency
    that plays a vital role in advancing transportation safety by
    investigating accidents, determining their causes, and issuing safety
    recommendations. From its creation in 1966 through 2006, NTSB has
    investigated more than 134,000 accidents in aviation and other modes of
    transportation and has issued over 12,500 safety recommendations across
    all modes. To support its mission, NTSB leases a training center that
    opened in 2003 and provides training to NTSB investigators and other
    transportation safety professionals. While new transportation technologies
    and NTSB's safety recommendations have made transportation safer than
    ever, the expected increase in the demand for all transportation modes
    will potentially place a strain on the ability of NTSB to continue playing
    its vital role in ensuring a safe transportation system in the United
    States. As the nation's large and growing long-term fiscal imbalance
    demands a growing share of federal resources, and a wide range of emerging
    needs and demands compete for a share of the budget, it is critical that
    NTSB use its resources in an efficient manner to carry out its safety
    mission and maintain its preeminent position. With a staff of 386 and a
    budget of $76.7 million in fiscal year 2006, the National Transportation
    Safety Board (NTSB) is a relatively small agency that plays a vital role
    in advancing transportation safety by investigating accidents, determining
    their causes, and issuing safety recommendations. From its creation in
    1966 through 2006, NTSB has investigated more than 134,000 accidents in
    aviation and other modes of transportation and has issued over 12,500
    safety recommendations across all modes. To support its mission, NTSB
    leases a training center that opened in 2003 and provides training to NTSB
    investigators and other transportation safety professionals. While new
    transportation technologies and NTSB's safety recommendations have made
    transportation safer than ever, the expected increase in the demand for
    all transportation modes will potentially place a strain on the ability of
    NTSB to continue playing its vital role in ensuring a safe transportation
    system in the United States. As the nation's large and growing long-term
    fiscal imbalance demands a growing share of federal resources, and a wide
    range of emerging needs and demands compete for a share of the budget, it
    is critical that NTSB use its resources in an efficient manner to carry
    out its safety mission and maintain its preeminent position.

    In light of NTSB's expansive mission to investigate transportation
    accidents across all modes and its relatively limited resources to
    accomplish this mission, you asked us to assess the agency's management
    practices and accident investigation activities in order to provide In
    light of NTSB's expansive mission to investigate transportation accidents
    across all modes and its relatively limited resources to accomplish this
    mission, you asked us to assess the agency's management practices and
    accident investigation activities in order to provide information to be
    considered during the reauthorization of NTSB. In doing so, we addressed
    the following questions: (1) To what extent does NTSB follow leading
    management practices? (2) How does NTSB carry out its accident
    investigation function? and (3) Is NTSB's training center a cost-effective
    investment, and how could it be more cost-effective?

    To determine the extent to which NTSB follows leading practices, we
    compared NTSB's practices with criteria from our past work in functional
    areas that we consider important for an agency to perform well
    in--strategic planning, human capital management, communications,
    acquisition management, financial accountability and control, information
    technology (IT), and knowledge management. We did not evaluate NTSB's
    performance in the area of capital decision making because the agency does
    not have a large amount of either capital assets or capital acquisitions.
    With assistance from GAO specialists in the functional areas, we assessed
    whether NTSB was mostly following the practices (plans or policies for all
    or nearly all practices have been developed and implemented properly),
    partially following them (plans or policies are in place and implemented
    properly for some practices), or minimally following them (plans or
    policies are lacking for all or nearly all practices). We also reviewed
    NTSB's responses to recommendations in some of these functional management
    areas made by us and the Department of Transportation's Inspector General
    (DOT IG) in recent years. We interviewed current and former NTSB board
    members, senior officials, and division managers regarding their
    experience with those practices at NTSB and their perceptions of the
    effectiveness of those practices. We reviewed NTSB documents including
    orders, operations bulletins, investigative manuals, management plans, and
    applicable legislation. To determine how NTSB carries out its accident
    investigation function, we interviewed current and former board members,
    senior officials, division managers, and selected staff. We randomly
    selected 17 of the 203 investigators and 8 writer-editors, who assist in
    writing accident investigation reports, roughly evenly across NTSB's four
    modal offices.^1 The views represent the particular individuals and are
    not representative of all NTSB investigators and writer-editors. We also
    interviewed industry and government stakeholders, including federal
    agencies that receive NTSB recommendations; aviation, rail, marine, and
    highway associations; and transportation safety advocacy groups. In
    addition, we examined data on the number and implementation status of
    safety recommendations from NTSB's recommendation database, and we
    determined the data were sufficiently reliable for this review. We
    reviewed legislation, policy guidance, and NTSB data on the investigative
    process. Additionally, we reviewed studies by RAND Corporation and Booz
    Allen Hamilton that examined NTSB's investigation process and determined
    the extent to which the agency had implemented their recommendations. To
    determine the extent to which NTSB's training center is a cost-effective
    investment and how it could be more cost-effective, we reviewed financial
    data on NTSB's training center, including the revenues and expenses for
    fiscal years 2004 and 2005, and we examined NTSB's lease to determine how
    NTSB may utilize the space. We conducted our review from December 2005 to
    November 2006 in accordance with generally accepted government auditing
    standards. For more information on our scope and methodology, see appendix
    I.

    ^1The four offices are Aviation Safety; Highway Safety; Marine Safety; and
    Railroad, Pipeline, and Hazardous Materials Safety.

    Results in Brief

    While NTSB has recently made progress in following leading management
    practices in the seven areas we examined, overall, it either minimally or
    partially has plans or policies in place to implement those practices.
    NTSB minimally follows leading practices in strategic planning, IT, and
    knowledge management. NTSB partially follows leading practices in the
    areas of human capital management, communications, acquisition management,
    and financial accountability and control. For example, NTSB's strategic
    plan lacks results-oriented objectives and specific strategies for
    achieving them, which are important practices in helping an agency to
    define and support its mission, as well as a strategy for managing a
    diverse workforce as part of the strategic plan's discussion of human
    capital. In May 2006, we recommended that NTSB improve its strategic plan,
    and it is taking steps to do so.^2 Regarding IT, in previous work we
    identified key elements of an IT program--an IT strategy, enterprise
    architecture, IT investment management, and information security--that can
    help agencies maximize the value of their IT investments and improve
    agency performance. While NTSB has made recent progress in correcting some
    information security vulnerabilities identified by the DOT IG, the agency
    has not completed its information security efforts, developed an IT
    strategic plan, established an enterprise architecture, or initiated an IT
    investment management process. In addition, NTSB does not have a knowledge
    management initiative (i.e., a way for an organization to create, capture,
    and reuse knowledge to achieve its objectives) or a Chief Information
    Officer, which are essential to improving an organization's ability to
    create and share knowledge, including data and information. NTSB is
    partially following leading practices in human capital management. For
    example, NTSB developed a staffing plan that addresses the agency's
    skills, competency needs, and hiring strategies to strengthen the agency's
    ability to carry out its transportation safety mission. However, the
    agency lacks a strategic training plan, which is important for ensuring
    that an organization has strategies for developing and training staff with
    the appropriate mix of skills and capabilities to achieve its mission.
    With regard to communication practices, NTSB has recently taken positive
    steps to improve communications from senior management to the staff--such
    as periodically sending e-mails to all staff to share information on new
    developments and policies. However, the agency lacks upward communications
    mechanisms, which are central to forming effective partnerships within the
    organization. In May 2006, we made recommendations in this area, and NTSB
    is taking steps to follow them.^3 While NTSB is partially following
    leading acquisition practices, such as having a Chief Acquisition Officer
    and strategically assessing acquisition needs, the agency does not have an
    acquisition policy to guide IT activities, thereby increasing the risk
    that the agency will not be able to effectively manage new IT programs as
    they are acquired and come online. Finally, NTSB follows some leading
    practices for financial accountability and control and has received an
    unqualified or "clean" opinion from independent auditors on its financial
    statements in recent years. However, the agency lacks a full cost
    accounting system, which would inform managers of the resources spent on
    individual investigations and provide data to help assure balanced office
    workload. In addition, it has also violated the Anti-Deficiency Act
    because it did not obtain budget authority for the net present value of
    the entire 20-year lease for its training center lease obligation at the
    time the lease agreement was signed in 2001.

    ^2GAO, National Transportation Safety Board: Preliminary Observations on
    the Value of Comprehensive Planning, and Greater Use of Leading Practices
    and the Training Academy, [42]GAO-06-801T (Washington, D.C.: May 24,
    2006).

    NTSB carries out its transportation safety function by selecting which
    accidents to investigate, sometimes using outside sources of expertise to
    help it determine the probable cause of those accidents, issuing
    suggestions and recommendations, and taking proactive steps outside of
    specific accidents. For some transportation modes, NTSB has detailed,
    risk-based criteria for selecting which accidents to investigate, while
    for others it does not. For example, in an effort to manage resources and
    ensure the maximum safety benefit, NTSB has a process to identify highway
    accidents for investigation based on the severity of the accident and
    amount of property damage. By comparison, NTSB lacks a documented policy
    with criteria for selecting rail, pipeline, and hazardous materials
    accidents to investigate. Instead, the decision to investigate an accident
    is made by the office Director based on his judgment. As a result, for
    these modes, the agency lacks assurance and transparency that it is
    managing resources in a manner that ensures a maximum safety benefit. Such
    criteria are also important because NTSB does not have enough resources to
    investigate all accidents. Moreover, NTSB must allocate a large proportion
    of its resources to investigating aviation accidents due to a statutory
    requirement that NTSB investigate all civil aviation accidents, including
    general aviation accidents. In fact, NTSB investigated nearly 2,000
    aviation accidents in 2005 compared with 47 in all the other
    transportation modes combined. This requirement, therefore, reduces the
    number of staff that NTSB can use to investigate accidents in other modes
    that may have broader or more critical safety implications. To its credit,
    although accident investigations are sometimes lengthy, NTSB takes steps
    to ensure that recommendations for improving transportation safety are
    made available to the transportation industry before a report is issued by
    making "urgent" recommendations and suggestions for improvement during the
    course of an investigation. Since 2001, according to NTSB's records, 256
    NTSB suggestions have been implemented. Another strength of NTSB's process
    is its use of external sources of technical expertise and occasionally
    public hearings. Finally, NTSB proactively accomplishes its transportation
    safety function by conducting public forums and safety studies to consider
    safety issues that may be relevant to more than one accident in order to
    provide improvements to transportation safety. Safety studies, which
    sometimes result in recommendations, are intended to improve
    transportation safety by affecting changes to policies, programs, and
    activities of federal agencies that regulate transportation safety. Over
    the last 6 years, NTSB has conducted four safety studies. Industry
    stakeholders stated they would like NTSB to conduct more safety studies
    because the studies address NTSB's mission in a proactive way, allowing
    for trend analysis and preventative actions. According to NTSB, the number
    of safety studies it conducts is resource driven.

    ^3 [43]GAO-06-801T .

    While NTSB staff and other students at NTSB's training center have been
    positive about the quality of the courses, NTSB's training center is not
    cost-effective, as the combination of the training center's revenues and
    external training costs avoided by NTSB staff's use of the facility do not
    cover the training center's costs. For the first 2 full years of
    operation, fiscal years 2004 and 2005, NTSB's training center did not
    generate sufficient revenues to cover the costs of providing training
    there. As a result, those portions of the training center's costs that
    were not covered by the revenues from tuition and other
    sources--approximately $6.3 million in fiscal year 2004 and $3.9 million
    in fiscal year 2005--were offset by general appropriations to the agency.
    Moreover, thus far the training center has had a limited impact in terms
    of avoiding external training costs, as the majority of NTSB staff
    training occurs externally. Revenues generated by the training center are
    affected by several factors, including low utilization of the facility and
    the availability of similar courses elsewhere that may reduce the number
    of students interested in NTSB classes. Potential strategies to increase
    revenues or decrease costs could increase the cost-effectiveness of the
    training center. For example, NTSB could attempt to increase training
    center revenues by attracting more external students, or decrease its
    external training costs by focusing on gearing more courses to NTSB staff,
    but it may be difficult to accomplish either of these strategies
    sufficiently to significantly affect the training center's overall
    deficit, since NTSB lacks a market niche for its course offerings, and
    NTSB's external training costs for its staff--approximately $1 million
    annually--are well below the $3.9 million deficit in fiscal year 2005.
    NTSB could also sublet space to other users, such as academic users, but
    subleasing may not help NTSB to recover training center costs. NTSB could
    also consider relocating some headquarters staff to the training center,
    although such a move would incur other costs. NTSB officials agreed with
    our analysis that vacating the space may be the least-cost strategy, even
    if NTSB had to buy out the remaining lease.

    To improve overall agency operations, we recommend that NTSB fully
    implement leading management practices in several areas, develop
    risk-based criteria for determining which accidents to investigate in all
    modes, increase its utilization of safety studies, finalize a solution to
    its Anti-Deficiency Act violation that has continued since the signing of
    the lease in 2001, and develop a business plan to either increase the
    utilization of its training center or vacate it. NTSB agreed with these
    recommendations.

    Background

    NTSB was established in 1966 as an independent government agency located
    within the newly formed Department of Transportation (DOT).^4 In 1974,
    Congress made NTSB completely separate from DOT.^5 NTSB's principal
    responsibility is to promote transportation safety by investigating
    transportation accidents, determining the probable cause, and issuing
    recommendations to address safety issues identified during accident
    investigations. As figure 1 indicates, NTSB has varying degrees of
    flexibility in its statutory mandate, as it pertains to initiating an
    investigation. By statute, NTSB has limited discretion in deciding which
    aviation accidents to investigate and the greatest amount of discretion in
    deciding whether to investigate highway accidents.

    ^4Department of Transportation Act, Pub. L. No. 89-670, Oct. 15, 1966.

    ^5Independent Safety Board Act, Pub. L. No. 93-633, Title III, 1974.

    Figure 1: Key Laws, Regulations, and NTSB Policies for Investigations by
    Mode

    Unlike regulatory transportation agencies, such as the Federal Aviation
    Administration (FAA), NTSB does not have the authority to promulgate
    regulations to promote safety, but it makes recommendations in its
    accident investigation reports and safety studies to other agencies that
    have such regulatory authority. The federal agencies that receive NTSB
    recommendations^6 include DOT's FAA, Federal Highway Administration
    (FHWA), Federal Motor Carrier Safety Administration (FMCSA), Federal
    Railroad Administration (FRA), Federal Transit Administration (FTA),
    National Highway Traffic Safety Administration (NHTSA), Pipeline and
    Hazardous Materials Safety Administration (PHMSA), and the U.S. Coast
    Guard within the Department of Homeland Security. Some of these federal
    agencies--including FAA, FRA, and the Coast Guard--also conduct
    transportation accident investigations. Table 1 shows NTSB's workload by
    transportation mode over 4 years.

    Table 1: Number of Accident Investigations Completed by NTSB by Mode,
    Fiscal Years 2002-2005

    Mode                  2002    2003  2004 2005
    Aviation^a          1,949  1,997  1,870 1,937
    Highway                52     45     45    33
    Rail                   11      9     12     8
    Pipeline                1      2      2     1
    Hazardous materials     2      1      2     1
    Marine                  6      6      7     4

    Source: GAO analysis of NTSB data.

    aAviation accidents include limited investigations in which NTSB delegates
    the gathering of on-scene information to FAA inspectors.

    NTSB's Organization and Resources

    NTSB's board is composed of five members nominated by the President and
    confirmed by the Senate.^7 The Chairman is NTSB's Chief Executive and
    Administrative Officer. As of September 2006, the board was supported by a
    staff of 386, which includes 203 investigators and technical staff
    assigned to four modal offices--aviation; highway; marine; and rail,
    pipeline, and hazardous materials--and the Office of Research and
    Engineering. Figure 2 shows NTSB's organization.

    ^6NTSB also makes recommendations to others, such as state transportation
    authorities and industries.

    ^7The Chairman is nominated by the President with the advice and consent
    of the Senate. The Vice Chairman is appointed by the President.

    Figure 2: NTSB's Organization

    The agency is headquartered in Washington, D.C., and maintains 10 field
    offices nationwide and a training center in Ashburn, Virginia, in suburban
    Washington, D.C. In recent years, the agency has shrunk in size. In 2003,
    NTSB had 438 full-time employees compared with 386 in September 2006.
    During the same period, the number of full-time investigators and
    technical staff decreased from 234 to 203. (See fig. 3.) NTSB's modal
    offices vary in size in relation to the number of investigators; as of
    September 2006, the aviation office had 102 investigators and technical
    staff; the rail, pipeline, and hazardous materials office had 31; the
    highway office had 22; and the marine office had 12 employees. An
    additional 36 technical staff worked in the Office of Research and
    Engineering, which provides technical, laboratory, analytical, and
    engineering support for the modal investigation offices. For example, it
    is responsible for interpreting data recorders, creating accident computer
    simulations, and publishing general safety studies.

    Figure 3: Number of NTSB Investigators and Technical Staff, Fiscal Years
    2000-2007

    Note: Fiscal years 2000 and 2001 data are presented as of the second month
    of the fiscal year. Fiscal years 2002-2006 are presented as of the first
    pay period for each fiscal year. Fiscal year 2007 is presented as of the
    last pay period of fiscal year 2006.

    NTSB has approximately $28 million in capital assets. The vast majority of
    these assets--88 percent of the value--are made up of the capital lease on
    the training center and equipment, furniture, and desktop computers to
    furnish the training center. (See table 2.)

    Table 2: NTSB Training Center and Headquarters Capital Assets, as of
    September 2006

    Training center                              Acquisition value
    Lease value                                        $23,731,941
    Equipment value                                        211,485
    Furniture value                                        347,641
    Desktop computers value                                307,353
    Training center total value                        $24,598,420
    Headquarters
    Materials lab                                       $1,590,797
    All other headquarters value                         1,862,188
    Headquarters total value                            $3,452,985
    Training center and headquarters total value       $28,051,405

    Source: GAO analysis of NTSB data.

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

    NTSB's budget increased from $62.9 million in fiscal year 2001 to $76.7
    million in fiscal year 2006, or about 22 percent. After adjusting for
    inflation, this represents an increase of about 9 percent. The President
    requested $79.6 million for NTSB in fiscal year 2007.^8

    Investigative Process

    Investigations have four phases--the "launch," fact finding, analysis, and
    report production. After a report is issued and recommendations made, NTSB
    tracks the progress of implementing the recommendations during a fifth
    closeout phase. Figure 4 describes these phases.

    ^8As of November 3, 2006, the House had approved NTSB's fiscal year 2007
    budget at $81,594,000, and the Senate Appropriations Committee approved a
    level of $79,594,000.

    Figure 4: Components of an NTSB Investigation and Recommendation Closeout

    aIIC is the "investigator-in-charge."

    bThe group chairman is a technical specialist who is responsible for
    developing the facts and analysis for a particular area of an
    investigation.

    When a major accident^9 occurs, a team of investigators is dispatched
    usually within hours of notification of the accident. All marine, rail,
    pipeline, hazardous material, and highway accidents^10 that NTSB
    investigates are designated as major accidents. For aviation accidents,
    NTSB conducts on-scene investigations of major accidents and more limited
    investigations of accidents not designated as major. In some cases, for
    on-scene investigations, the team members must set aside the
    investigations they have been working on to begin fact-finding on the new
    accident. The team begins the on-scene investigation as quickly as
    possible and assembles the technical expertise that is needed to solve
    sometimes complex transportation safety problems associated with the
    accident. The team's leader is a senior investigator called the
    "investigator-in-charge;" other investigators contribute as specialists
    responsible for a clearly defined portion of the accident
    investigation.^11 Under the direction of the investigator-in-charge, each
    NTSB investigator heads a working group in one area of expertise, which is
    staffed by representatives of the "parties" to the investigation. Parties
    are typically entities that can provide the necessary technical assistance
    to the investigation.^12 For example, parties to an aviation accident may
    be the aircraft manufacturer and the pilots' union; by statute, FAA is
    always a party to aviation investigations. At major accidents, NTSB's
    Office of Transportation Disaster Assistance^13 ensures that families and
    victims' representatives have access to information concerning an accident
    throughout each phase of the investigation. This office coordinates
    briefings and provides support to families at the accident site by
    answering questions and guiding the families through the investigation
    process.^14

    9NTSB defines a major accident as one that involves an issue related to a
    current safety study or special investigation, impacts public confidence
    or transportation safety in a significant way, or is catastrophic.

    ^10NTSB investigates accidents involving all types of highway vehicles,
    including automobiles, buses, and trucks.

    Upon analyzing information obtained from parties and other sources, NTSB
    analysts prepare the accident investigation report, which is then reviewed
    throughout the agency. A report is typically reviewed by the modal office,
    the Office of Research and Engineering, the Executive Secretariat, the
    Office of Safety Recommendations and Communications, the Office of General
    Counsel, and the Managing Director's Office. A final report is then
    submitted to each board member and the Chairman perhaps 12 to 18 months
    from the date of the accident. Final reports typically include
    recommendations.

    ^11For example, in aviation, these specialists and their responsibilities
    are operations, structures, power plants, systems, air traffic control,
    weather, human performance, and survival factors. Locomotive engineers,
    signal system specialists, and track engineers head working groups at
    railroad accidents. The specialists at a highway accident include a truck
    or bus mechanical expert and a highway engineer. The agency's weather,
    human performance and survival factors specialists respond to accidents of
    all kinds.

    ^12Only those persons who can provide NTSB with needed technical or
    specialized expertise are permitted to serve on the investigation; persons
    in legal or litigation positions are not allowed to be assigned to the
    investigation.

    ^13The Office of Transportation Disaster Assistance is located in NTSB's
    Office of Safety Recommendations and Communications. Family affairs
    specialists accompany the team to fulfill NTSB's responsibilities under
    the Aviation Disaster Family Assistance Act of 1996, Pub. L. No. 104-264,
    Title VII-Family Assistance, October 9, 1996.

    ^14After the on-scene investigation has been concluded, the Office of
    Transportation Disaster Assistance continues its assistance through a
    dedicated telephone answer line that families and victims' representative
    can call and receive information with a guaranteed response time of 2
    hours. Family members are also notified of other events relating to the
    accident such as public hearings and receive the final investigative
    report.

    Leading Management Practices

    Through our work governmentwide, we have identified a number of leading
    practices in areas that are important for managing an agency. Although
    NTSB is a relatively small agency, such practices are relevant for any
    agency. We evaluated NTSB's practices based on leading practices
    identified in prior GAO work. (Related GAO products are listed at the end
    of this report.) In May 2006, we reported preliminary information
    concerning how NTSB's practices compare with leading practices in the
    areas of strategic planning, human capital management, communications, and
    financial accountability and control.^15 This report focuses on NTSB's
    performance in those areas, as well as acquisition management, IT, and
    knowledge management.

    NTSB Has Made Recent Progress in Following Leading Management Practices, but
    Overall Record Remains Mixed

    While NTSB has recently made progress in following leading management
    practices, its overall record in following such practices is mixed. As
    illustrated in figure 5, NTSB minimally follows leading practices in
    strategic planning, IT, and knowledge management. In the areas of human
    capital management, communications, acquisition management, and financial
    accountability and control, it partially follows leading practices. Much
    of NTSB's progress toward following leading practices is due to recent
    management initiatives. However, NTSB lacks a human capital plan that
    includes strategies on staffing, training, diversity management, and
    recruitment and retention; a comprehensive strategic plan; a knowledge
    management plan; and an IT management process. In May 2006, based on our
    preliminary work, we made recommendations to NTSB to address some of these
    areas. (App. II lists our previous recommendations.)

    ^15 [44]GAO-06-801T .

    Figure 5: Extent to Which NTSB Follows Leading Practices in Selected
    Management Areas

    NTSB's Strategic Plan Lacks Certain Performance-Based Elements

    NTSB's strategic plan minimally follows leading performance-based
    practices. Without effective short- and long-term planning, federal
    agencies risk delivering programs and services that may not meet the
    nation's most critical needs. The Government Performance and Results Act
    of 1993 (GPRA)^16 and guidance contained in the Office of Management and
    Budget Circular A-11, provide performance-based strategic planning
    guidelines. GPRA requires federal agencies, including NTSB, to develop
    strategic plans in which they define their missions, establish
    results-oriented goals, and identify the strategies that will be needed to
    achieve those goals. Such a plan can help to directly link efforts such as
    training to the organization's strategic goals and help to ensure that the
    skills and competencies of its workforce enable the organization to
    perform its mission effectively. To its credit, in December 2005, NTSB
    issued a strategic plan for fiscal years 2006 through 2010, which was the
    first time the agency had a strategic plan in 6 years. We compared NTSB's
    strategic plan with selected elements required by GPRA. (See fig. 6.)

    ^16Pub. L. No. 103-62.

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

    While NTSB's 5-year strategic plan has a mission statement, four general
    goals and related objectives, and mentions key factors, such as declining
    resources, that could affect the agency's ability to achieve those goals,
    the plan lacks a number of key elements--including information about the
    operational processes; skills and technology; and the human, capital, and
    information resources--required to meet the goals and objectives. In
    addition, the goals and objectives lack sufficient specificity to know
    whether they have been achieved, and the plan lacks specific strategies
    for achieving those goals. According to GPRA, the strategies should
    include a description of the operational processes, skills and technology,
    and the resources required to meet the goals and objectives. Since NTSB's
    strategic plan lacks such a description, it does not align staffing,
    training, or other human resource management to strategic goals. In May
    2006, we recommended that NTSB revise its strategic plan.^17 In response
    to our recommendation, NTSB hired a contractor to assist in revising the
    strategic plan. The statement of work for the contract called for a more
    comprehensive and results-oriented plan that included the GPRA elements
    that are missing or incomplete in the current plan. As of October 2006,
    the first draft of the revised plan had been prepared. NTSB expects to
    issue the new plan in January 2007.

    ^17 [45]GAO-06-801T .

    NTSB Is Partially Following Leading Human Capital Practices

    Federal agencies are experiencing pervasive human capital challenges in
    acquiring and developing staffs to meet current and emerging agency needs.
    Human capital management consists of several key management elements,
    including workforce planning; performance management; training;
    recruiting, hiring, and retention; and diversity management. As
    illustrated in figure 7, NTSB is partially following leading practices in
    workforce planning; performance management; and recruiting, hiring, and
    retention and is minimally following leading practices in training and
    diversity management.

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

      NTSB's Staffing Plan Is a Step in the Right Direction for Workforce Planning,
      but the Organizational Structure Has Not Been Reviewed

    NTSB is partially following leading practices in workforce planning. NTSB
    developed a draft agencywide staffing plan in December 2005 that follows
    several leading practices but lacks other leading practices such as a
    workforce deployment strategy that considers the organizational structure
    and its balance of supervisory and nonsupervisory positions. Existing
    strategic workforce planning tools and models suggest that certain
    principles should be followed in strategic workforce planning, such as
    determining the agency's skills and competencies needs, involving
    stakeholders (e.g., management and employees) in the planning process, and
    developing succession plans to anticipate upcoming employee retirement and
    workforce shifts. Further, in workforce deployment, it is important to
    have human capital strategies to avoid excessive organizational layers and
    to properly balance supervisory and nonsupervisory positions. NTSB's draft
    staffing plan addresses the agency's skills and competencies needs and
    includes strategies to deal with workforce shifts. For example, the draft
    staffing plan proposes to increase the number of investigative staff by
    21, which will help with the agency's resource needs. In addition, while
    some stakeholders (i.e., managers) were involved in the planning process,
    employees were not included. Employee input provides greater assurance
    that new policies are accepted and implemented because employees have a
    stake in their development.

      Performance Management Plans Closely Follow Leading Practices but Are Not
      Fully Functional

    NTSB is partially following leading practices in performance management.
    In prior work, we reported that performance management systems are crucial
    for agencies because, if developed properly, they allow employees to make
    meaningful contributions that directly contribute to agency goals.^18 NTSB
    has begun to develop a performance management system that should
    eventually link each individual's performance throughout the agency to the
    agency's strategic goals and objectives. NTSB has a comprehensive
    performance management plan for Senior Executive Service employees that
    links individual performance to strategic goals. This plan states that
    NTSB will link performance management with the agency's results-oriented
    goals and set and communicate individual and organizational goals and
    expectations. Because NTSB recognizes in this plan the importance of
    aligning organizational performance with individual performance and
    contributions to the agency's mission, the performance management plan is
    a step in the right direction. Furthermore, NTSB issued, in August 2005, a
    performance plan for its overall workforce, which includes some elements
    of linking individual performance to organizational goals. However,
    without having results-oriented goals in the strategic plan itself,
    neither of the two performance management plans is fully functional. That
    is, until NTSB's goals are more fully articulated in the strategic plan,
    it may be difficult for staff to know whether their performance
    contributes to meeting those goals. As with the 2005 strategic plan, NTSB
    staff were not involved in the development of the performance plan, and
    there was no mechanism for employee feedback after the plan was initially
    developed.

    ^18GAO, Results Oriented Cultures: Creating a Clear Linkage between
    Individual Performance and Organizational Success, [46]GAO-03-488
    (Washington, D.C.: Mar. 14, 2003).

      NTSB Lacks a Strategic Approach to Training Staff

    NTSB is minimally following leading practices in training, which is
    another key area of human capital management. It is important for agencies
    to develop a strategic approach to training their workforce, which
    involves establishing training priorities and leveraging investments in
    training to achieve agency results, identifying specific training
    initiatives that improve individual and agency performance, ensuring
    effective and efficient delivery of training opportunities in an
    environment that supports learning and change, and demonstrating how
    training efforts contribute to improved performance and results.^19 NTSB
    has neither developed a strategic training plan, nor has it identified the
    core competencies needed to support its mission and a curriculum to
    develop those competencies. Although NTSB staff annually identify training
    to improve individual performance, as a result of not having a core
    curriculum that is linked to core competencies and the agency's mission,
    NTSB lacks assurance that the courses that staff take provide the
    technical knowledge and skills necessary for them to be competent for the
    type of work they perform. We recommended that NTSB develop a strategic
    training plan.^20 In response, NTSB plans to hire a training officer and
    begin addressing this recommendation.

      NTSB Uses Flexibilities to Recruit and Retain Staff, but Strategic Recruiting
      and Succession Planning Is Lacking

    NTSB is partially following leading management practices for recruitment
    and retention. People are an agency's most important organizational asset.
    With the increasing numbers of employees retiring and the numbers of
    employees who will be eligible to retire in the near future, along with
    competition from private companies, federal agencies are in a struggle to
    recruit and retain highly skilled employees. To deal with the challenges
    in acquiring and developing staffs to meet current and emerging agency
    needs, we have reported that agencies need effective human capital
    flexibilities to assist them.^21 In broad terms, human capital
    flexibilities represent the policies and practices that an agency has the
    authority to implement in managing its workforce to accomplish its mission
    and achieve its goals. The tailored use of such flexibilities for
    acquiring, developing, and retaining talent is an important cornerstone of
    our model of strategic human capital management, which we issued to assist
    in transforming agencies so they become more results-oriented, integrated,
    and externally focused.^22 We have reported that agencies find work-life
    policies and programs, such as alternative and flexible work schedules,
    transit subsidies, child care assistance, and employee assistance
    programs, to be the most effective human capital flexibilities available
    in federal agencies for managing the workforce to achieve agency missions
    and accomplish agency goals. Other effective flexibilities include
    monetary recruitment and retention incentives, student employment and
    outstanding scholar programs, and performance incentives or time-off
    awards.

    ^19GAO, Human Capital: A Guide for Assessing Strategic Training and
    Development Efforts in the Federal Government, [47]GAO-04-546G
    (Washington, D.C.: Mar. 1, 2004).

    ^20 [48]GAO-06-801T .

    ^21GAO, Human Capital: Effective Use of Flexibilities Can Assist Agencies
    in Managing Their Workforces, [49]GAO-03-2 (Washington, D.C.: Dec. 6,
    2002).

    NTSB has implemented several flexibilities--such as alternative work
    arrangements, recruiting and relocating bonuses, and performance
    incentives and awards--to assist with recruiting and retention.
    Furthermore, NTSB employees are eligible to participate in federal transit
    fare subsidies and flexible spending account programs. NTSB also offers
    employees health and wellness services and health club fee reimbursements.
    We recognize that agencies need to be able to identify and select the
    recruitment and retention incentives that are most appropriate and
    effective. For instance, we have reported that student loan repayment
    programs show promise as effective tools for attracting and retaining the
    talent needed to sustain the federal workforce.^23 Although NTSB does not
    have such a program, NTSB employees can be reimbursed--based on funds
    availability--for completed university courses related to their current
    position. NTSB has also established student and internship programs for
    investigative, technical, administrative, and professional functions where
    participants are often converted to permanent appointments. These kinds of
    programs and opportunities help attract and retain talent in an agency.

    As mentioned earlier in this report, NTSB's staffing plan is a step in the
    right direction for workforce planning purposes, but strategic workforce
    planning is also needed to attract and retain employees with the skill
    sets the agency needs to achieve its mission. NTSB does not have a
    strategic recruiting and retention policy. NTSB does have a recruitment
    and relocation bonus policy and a newly established policy for candidate
    selection, but these policies are limited in scope and do not align key
    skill sets with agency's strategic goals. Furthermore, NTSB does not have
    any succession plans. The Federal Workforce Flexibility Act of 2004
    requires the head of each agency to establish, in consultation with the
    Office of Personnel Management (OPM), a comprehensive management
    succession program to provide training for employees and develop future
    managers for the agency.^24 We have reported that leading organizations
    use succession planning as a strategic planning tool that focuses on
    current and future needs and develops pools of high-potential staff in
    order to meet the organization's mission over the long term.^25 Succession
    planning is used to help the organization become what it needs to be,
    rather than simply to recreate the existing organization. Also, given the
    retirement projections for the federal government that could create
    vacancies, agencies can use succession planning as a critical tool in
    their efforts to enhance diversity in their leadership positions.

    ^22GAO, A Model of Strategic Human Capital Management, [50]GAO-02-373SP
    (Washington, D.C.: Mar. 15, 2002).

    ^23GAO, Federal Student Loan Repayment Program: OPM Could Build on Its
    Efforts to Help Agencies Administer the Program and Measure Results,
    [51]GAO-05-762 (Washington, D.C.: July 22, 2005).

    Retention is important for an agency, such as NTSB, where employees have
    unique skill sets that cannot be easily replaced. When employees leave an
    agency, a formal exit interview process allows agency officials to obtain
    detailed, firsthand information on employees' reasons for separation that
    would allow management to analyze and address issues that could affect
    retention and take appropriate follow-up actions, such as improving
    training, career development opportunities, and communication. NTSB does
    not conduct exit interviews with departing employees.

      NTSB Is Not Following Most Diversity Management Leading Practices

    NTSB is minimally following leading practices in diversity management. We
    have reported that a high-performing organization relies on a dynamic
    workforce with the requisite talents, multidisciplinary knowledge, and
    up-to-date skills to ensure that it is equipped to accomplish its mission
    and achieve its goals.^26 Such organizations provide both accountability
    and fairness for all employees and draw on the strengths of employees at
    all levels and of all backgrounds. Diversity management is a process
    intended to create and maintain a positive work environment where the
    similarities and differences of individuals are valued, so that all can
    reach their potential and maximize their contributions to an
    organization's strategic goals and objectives. We identified nine leading
    practices for diversity management. (See fig. 8.)

    ^24NTSB is required, under the Federal Workforce Flexibility Act (5 U.S.C.
    S 4121), to establish a comprehensive management succession program.
    NTSB's board members, as presidential appointees, are exempt from this
    requirement. OPM has not yet promulgated required regulations under this
    act, and NTSB has yet to develop its program.

    ^25GAO, Human Capital: Selected Agencies Have Opportunities to Enhance
    Existing Succession Planning and Management Efforts, [52]GAO-05-585
    (Washington, D.C.: June 30, 2005).

    Figure 8: Leading Practices in Diversity Management

    NTSB minimally follows identified leading diversity management practices.
    For example, NTSB has not integrated diversity management into its
    strategic plan. As required, NTSB submitted its annual status reports to
    the U.S. Equal Employment Opportunity Commission in fiscal years 2004 and
    2005 including some recruiting objectives.^27 NTSB also submitted a
    Federal Equal Opportunity Recruitment Program Report to OPM for fiscal
    year 2006 that highlights some proposed actions for future hiring.^28 For
    instance, the NTSB report proposes to target recruiting to disabled
    veterans, women, and minority professional organizations such as the
    Organization of Black Airline Pilots, the National Society for Black
    Engineers, and the Society for Hispanic Engineers. NTSB's report also
    calls for distribution of information to managers regarding recruitment
    sources such as internship and scholarship programs. The report states
    that NTSB will determine the feasibility of cooperative agreements with
    universities with large percentages of minority students. However, there
    are no deadlines tied to these proposed actions, and accountability for
    activities is not assigned. As mentioned above, NTSB does not have any
    succession plans and is, therefore, not using that process to assist with
    diversity management. NTSB also lacks a formal mentoring program and does
    not have advisory groups to foster employee involvement in diversity
    management.

    ^26GAO, Diversity Management: Expert-Identified Leading Practices and
    Agency Examples, [53]GAO-05-90 (Washington, D.C.: Jan. 14, 2005).

    ^27Federal agencies are to report annually to the Equal Employment
    Opportunity Commission on their progress in establishing and maintaining
    continuous programs of equal employment opportunity, including workforce
    data collected and analyzed by race, gender, national origin, and
    disability; a description of identified barriers to equal employment
    opportunity; and a plan for eliminating or moderating such barriers.

    Communications from Senior Management to Staff Have Increased, but Upward
    Communications Mechanisms Are Lacking

    NTSB is partially following leading practices related to managing
    employees that include seeking and monitoring employee attitudes,
    encouraging two-way communication between employees and management, and
    incorporating employee feedback into new policies and procedures.^29 In
    response to issues raised by NTSB employees in a governmentwide survey
    conducted by OPM in 2004, NTSB's senior management made changes to improve
    the way they communicate information to staff. For example, the Managing
    Director periodically sends "management advisory" e-mails to all staff
    that share information such as policy changes or new developments at the
    agency. However, we found no formal processes that encouraged two-way
    communication, such as town hall meetings, regular staff meetings, or
    confidential employee surveys; or incorporated employee feedback into
    policy making. Communication and collaboration across offices at all
    levels can improve an agency's ability to carry out its mission by
    providing opportunities to share best practices and helping to ensure that
    any needed input is provided in a timely manner. In May 2006, we
    recommended that NTSB develop mechanisms that will facilitate
    communications from staff-level employees to senior management.^30 In
    response to this recommendation, NTSB has begun developing a
    communications plan. The agency has also begun activities to enhance
    communication from staff to management, such as outreach visits to
    regional offices and brown bag lunches with senior managers and board
    members. In addition, the agency conducted a survey in September 2006 to
    obtain employee input on its revised strategic plan. According to agency
    officials, although they have no set schedule for regional office visits
    and employee surveys, their goal is to continue the visits on an ad hoc
    basis and the survey on an as needed basis for specific purposes, such as
    to obtain more detailed, actionable information to followup on OPM's
    biennial employee survey.

    ^28Agencies are required to report annually to OPM concerning their
    Federal Equal Opportunity Recruitment Program, which is a program
    established by Congress and overseen by OPM to ensure equal employment
    opportunity in recruitment.

    ^29GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers
    and Organizational Transformations, [54]GAO-03-669 (Washington, D.C.: July
    2, 2003).

    Acquisition Management Has Made Significant Progress in Recent Years

    NTSB is partially following leading acquisition practices that promote an
    efficient and accountable acquisition environment and process. We found
    that leading organizations transform the acquisition function from one
    focused on supporting various business units to one that is strategically
    important to the bottom line of the whole organization. For example, NTSB
    has a Chief Acquisition Officer and is, for the most part, strategically
    assessing acquisition needs. After NTSB identified weakness in its small
    purchases program, audits by both GAO and DOT IG in the early 2000's
    identified weaknesses in the agency's financial internal controls.^31 As a
    result of these audits, NTSB undertook a number of initiatives to improve
    its acquisition activities. For example, NTSB established an Acquisition
    Division in October 2003 and hired an individual to manage the agency's
    acquisition program and to implement the GAO and DOT IG recommendations.
    In addition, NTSB's purchase card program was transferred to the
    Acquisition Division in fiscal year 2005. Upon assuming responsibility for
    this program, the division developed and implemented new purchase card
    policies and procedures. As part of these new procedures, the approving
    administrative officers at headquarters are responsible for purchasing
    office supplies and services for the agency, as needed, while
    investigators who hold purchase cards are limited to using them only on
    the scene of an accident during an investigation. NTSB also instituted a
    purchase limit for all staff. The single purchase limit is $2,500, and the
    monthly cycle-limit for purchases cannot exceed $25,000. NTSB also
    required that all purchase card holders and approving officials take an
    online General Services Administration (GSA) training course and
    additional NTSB training. Other controls to protect against fraud, waste,
    and abuse include certifying funds and obtaining approval from the
    cardholder's supervisor prior to making a purchase.^32 In addition, the
    cardholder's approving official reviews and approves cardholders' monthly
    statements. NTSB also performs random audits of cardholders' purchase card
    files to ensure that procedures are being adhered to. However, due to lack
    of staff in the 10 regional offices, the Acquisition Division has not
    randomly audited these purchase card holders. According to NTSB officials,
    they mitigate the risk associated with the lack of these audits by having
    the Chief Financial Officer (CFO) and the responsible approving official
    review all purchase card activity via the monthly Citibank transaction
    reports. However, unlike an audit, such a review does not assure that
    acquisition procedures are being followed.

    ^30 [55]GAO-06-801T .

    ^31DOT IG, National Transportation Safety Board: Rapiddraft Payment
    System, Statement of Kenneth M. Mead Before the Budget Committee Task
    Force on Housing and Infrastructure, U.S. House of Representatives, April
    13, 2000; GAO, National Transportation Safety Board: Weak Internal Control
    Impaired Financial Accountability, [56]GAO-01-1032 (Washington, D.C.:
    Sept. 28, 2001).

    Throughout the acquisition process, leading management practices have
    shown financial information should be tracked and communicated in a way
    that enables effective evaluation and assessment of acquisition
    activities. When financial data are not useful, relevant, timely, or
    reliable, the acquisition function--as well as other functions across an
    organization--are at risk of inefficient or wasteful business practices.
    NTSB is partially following this practice. For example, NTSB's purchase
    card program requires administrative and other key purchase card users to
    obtain quarterly lump sum funds approvals called credit authorizations.
    Once these cardholders have an approved credit authorization, they must
    prepare and submit to their supervisor a "credit buy" for every purchase.
    According to NTSB's purchase card procedures, a purchase cannot be made
    until funds have been certified, and a supervisor has approved the
    purchase. NTSB tracks and monitors both credit authorizations and credit
    buys using the Interior Department Electronic Acquisition System (IDEAS)
    Procurement Desktop, a Windows-based acquisition software application
    intended to facilitate the purchasing of goods and services. The program
    automates the entire purchasing process from creation of the purchase
    request to contract closeout. However, IDEAS cannot alert managers to
    identify when quarterly credit authorizations are running low and,
    therefore, there is a potential that more money can be spent than
    allotted. NTSB mitigates this risk by reviewing all purchases monthly.

    ^32Other positive steps taken by the Acquisition Division include
    providing monthly obligations reports to all office directors and focusing
    on customer outreach and education. The Acquisition Division has also
    hosted training classes for senior staff, administrative staff, and its
    Contracting Officer's Technical Representative to educate them on their
    responsibilities in the acquisition process.

    Effective acquisition planning for IT includes having a written
    organizational policy guiding acquisitions and an acquisition strategy
    that includes objectives, projected costs and schedules, and risks and
    addresses the entire project life cycle. NTSB is not using some key
    processes and capabilities needed to successfully handle IT acquisitions.
    Sound business practices call for agencies to establish acquisition
    policies for IT to institutionalize and guide activities, such as project
    planning, to include budgeting and scheduling, requirements management,
    and risk management.^33 NTSB does not have an agencywide policy specific
    to IT acquisitions, which increases the risk that NTSB will not be able to
    effectively manage new IT programs as they are acquired and come online.

    Other leading management practices in acquisition include strategically
    assessing the agency's needs and developing acquisition approaches to help
    the agency meet those needs, as well as leveraging the purchasing volume
    by identifying agencywide acquisitions of goods and services. In August
    2004, Booz Allen Hamilton recommended that NTSB consolidate the purchasing
    of office supplies, uniforms, and other equipment in order to gain
    efficiencies such as acquiring quantity discounts, allowing spending to be
    easily tracked, tracking supply usage and forecasting needs with ease, and
    accounting for office purchases. In response to this recommendation, NTSB
    now centrally purchases computers, copiers, protective equipment, and
    uniforms.^34 NTSB has also assessed and incorporated changes to enable its
    acquisition process to better respond to unforeseen external events and
    emergencies.^35 For example, NTSB was granted "special contracting
    authority" in the NTSB Reauthorization Act of 2003 to help it award
    contacts without competition in order to expedite accident investigations.
    Since the authority was granted, NTSB has used it 11 times for a total
    acquisition value of $98,744. This is compared with $8,110,165 in total
    contract award dollars in fiscal year 2004 and $10,482,001 in total
    contract award dollars in fiscal year 2005. NTSB also has an appropriated
    emergency fund of $2 million, which is used for acquisitions.^36 The
    emergency fund provides additional resources if NTSB requires additional
    funding during the course of an investigation to purchase products or
    services. NTSB has used this authority selectively. For example, in the
    last 8 years, NTSB has accessed the fund once in fiscal year 2002 for
    costs related to the crash of American Airlines flight 587 at Belle
    Harbor, New York, and, at that time, the disbursement was about a quarter
    of the fund or $491,687.

    ^33Carnegie Mellon University's Software Engineering Institute, recognized
    for its expertise in software and system processes, has developed the
    Capability Maturity Model(R) Integration (CMMI^sm) and a CMMI appraisal
    methodology to evaluate, improve, and manage system and software
    development processes. The CMMI model and appraisal methodology provide a
    logical framework for measuring and improving key processes needed for
    achieving quality software and systems.

    ^34NTSB's Acquisition Division processes approximately $10-12 million per
    year on contracts that include approximately 600 small acquisition actions
    that total under $100,000 per year. The division also processes contracts
    for NTSB's training center that usually amount to under $100,000 per year.

    NTSB Follows Certain Leading Practices in Financial Management but Lacks a Full
    Cost Accounting System and Is Not Compliant with the Anti-Deficiency Act

    NTSB is partially following leading practices in financial accountability
    and control. A key to financial accountability is obtaining accurate and
    useful information on a timely and ongoing basis to support day-to-day
    managerial decisions and oversight. Other financial leading management
    practices include clear, strong financial management leadership by
    establishing the CFO position with specific authority and functional
    responsibilities for improving financial management, conducting related
    long-range planning, preparing agencywide financial statements that are
    subject to independent audit and preparing an agencywide public
    accountability report. NTSB's CFO has emphasized the importance of sound
    financial management based on best practices and has taken an active role
    in managing internal controls and improving financial management. For
    example, the CFO oversees the monitoring and financial execution of the
    agency budget in relation to actual expenditures and reports this
    information via weekly reports and regular senior management meetings. The
    CFO also provides information and regular communication to program office
    administrative officers and attends program office meetings. NTSB also has
    an arrangement with the Department of Interior for personnel, payroll,
    accounting, and contracts and procurement systems. This arrangement allows
    the CFO to provide relevant financial and performance information to
    agency decision makers. Similar to private sector companies, government
    agencies are required to report their financial condition in publicly
    available financial statements. NTSB received an unqualified or "clean"
    opinion from independent auditors on its financial statements for the
    fiscal years ending September 30, 2003 through 2006. The audit reports
    concluded that NTSB's financial statements presented fairly, in all
    material respects, the financial position, net cost, changes in net
    position, budgetary resources, and financing in conformity with generally
    accepted accounting principles for those 4 fiscal years.

    ^35For example, NTSB has prepared annual procurement forecasts since
    fiscal year 2004 to assist the agency with planning and gaining
    efficiencies.

    ^36Based on information from the Managing Director, CFO, and the
    respective modal director, the Chairman makes the decision to make the
    emergency fund available for extraordinary accident investigation costs.

    While cost accounting systems^37 provide financial information that can be
    used to monitor ongoing operations, they also aid in planning for the
    future. We have reported that sound financial management is crucial for
    responsible stewardship of federal resources.^38 In 2000, RAND recommended
    that NTSB develop systems that would allow the agency to better manage its
    resources by permitting full-cost accounting of all agency activities and
    recommended this be completed within a year.^39 To accomplish this, RAND
    recommended putting in place a timekeeping system, in which individual
    project numbers were assigned to each investigation and support activity
    such as training. With this information, project managers could better
    understand how staff resources were utilized, and project workload could
    be actively monitored by the Managing Director. NTSB began to implement
    this recommendation by upgrading a software system in November 2005 that
    tracks employee annual leave and sick leave. However, the system is not
    being fully utilized to track the number of hours staff spend on each
    investigation. Also, this system is not used to track time staff spend in
    training or at conferences. As a result, RAND's previous conclusion that
    "NTSB managers have little information they can use to plan the
    utilization of staff resources or manage staff workloads properly" remains
    current. An NTSB official stated that a major challenge will be the
    cultural change to use the cost accounting system once installed because
    of the size of NTSB; some divisions only have 10-20 investigators, and the
    official stated that the division managers know the workload of each
    investigator. In May 2006, we recommended that NTSB develop a full
    cost-accounting system. NTSB agreed with the recommendation and told us
    that it will attempt to allocate funds in fiscal year 2007 to address this
    capability.

    ^37Cost accounting involves the accumulation and analysis of financial and
    nonfinancial data, resulting in the allocation of costs to organizational
    pursuits such as performance goals, programs, activities, and outputs.
    Nonfinancial data measure the occurrences of activities and can include,
    for example, the number of hours worked.

    ^38GAO, Executive Guide: Creating Value through World-class Financial
    Management, [57]GAO/AIMD-00-134 (Washington, D.C.: April 2000).

    ^39RAND Institute for Civil Justice, Safety in the Skies: Personnel and
    Parties in NTSB Aviation Accident Investigations (Santa Monica, CA.:
    2000).

    Finally, NTSB has been noncompliant with the Anti-Deficiency Act because
    it did not obtain budget authority for the net present value of the entire
    20-year training center lease obligation at the time the lease agreement
    was signed in 2001. This occurred as a result of NTSB classifying the
    lease as an operating lease rather than a capital lease. NTSB realized the
    error in 2003 and reported its noncompliance to Congress and the
    President. NTSB has proposed in the President's fiscal year 2007 budget to
    remedy this Anti-Deficiency Act violation by inserting an amendment in its
    fiscal year 2007 appropriation that would allow NTSB to fund this
    obligation from its salaries and expense account through fiscal year 2020.
    However, this proposal was removed once the budget went to the House and
    Senate Appropriations Committees and, at this time, leaves the
    Anti-Deficiency Act violation uncorrected. If this provision is not
    passed, NTSB will need to take action to correct the Anti-Deficiency Act
    violation. This could include obtaining a deficiency appropriation for the
    full amount of the lease, renegotiating, or terminating the lease so that
    it complies with the Anti-Deficiency Act, or obtaining authority to
    obligate lease payments using annual funds.

    NTSB Is Making Progress in IT Management but Still Lacks Key Components

    NTSB has made improvements in its IT program, but weaknesses persist.
    Federal agencies are increasingly relying on IT to facilitate mission
    support. Our previous work has identified key elements of an IT program,
    which include an IT strategic plan, enterprise architecture, IT investment
    management, and information security. At present, NTSB is minimally
    following leading IT management practices. Currently, NTSB does not have a
    strategic management plan for IT, and it has not developed an enterprise
    architecture plan for modernizing its IT systems. Similarly, NTSB also
    lacks an IT investment management process to control and evaluate the
    agency's IT investment portfolio. Additionally, in 2005, the DOT IG found
    significant weaknesses in NTSB's information security program and reported
    that NTSB computers were vulnerable to unauthorized access from both
    inside and outside the agency and that the agency had no system to
    identify security breaches on its network.^40

    NTSB has made some improvement to IT security in response to DOT IG
    recommendations. To manage information security risks, NTSB has instituted
    a program of intrusion detection and computer vulnerability scanning. NTSB
    has also invested in advanced training for IT staff on information
    security and has trained all users of the agency's computer system in
    computer security awareness. Furthermore, NTSB has created a Chief
    Information Officer (CIO) position, which will be responsible for IT.
    Although NTSB is actively recruiting for the position, it is still
    vacant.^41 However, NTSB has recently hired a deputy CIO who has expertise
    in enterprise architecture and IT investment management. Nonetheless, in
    October 2006, the DOT IG found that while NTSB has made a concerted effort
    to improve its information security program, its program still has
    significant deficiencies.^42

    NTSB Lacks a Knowledge Management Program

    NTSB is minimally following leading practices in knowledge management.
    Knowledge management includes four fundamental principles: leadership that
    articulates management's vision and goals (e.g., in written policies and
    guidance), processes (including performance measurements) to turn vision
    into reality, technology that allows implementation of goals and supports
    the processes, and a culture of knowledge sharing and reuse. Knowledge
    management is essential to an organization because it is a means by which
    people create and share knowledge, including data and information. Some
    key elements of knowledge management are having an agencywide knowledge
    management initiative and having a senior official who coordinates this
    initiative and integrates it with other areas of the organization.
    Although the 2004 OPM's Federal Human Capital Survey reported that over 90
    percent of NTSB employees were satisfied with the use of IT to gather and
    share knowledge, NTSB does not have a knowledge management initiative or
    program and lacks a CIO to implement policies and procedures on
    information sharing.

    ^40DOT IG, Information Security Program: National Transportation Safety
    Board, FI-2006-001 (Washington, D.C.: Oct. 7, 2005).

    ^41When the position becomes filled, NTSB expects that the CIO will focus
    upon maintaining the NTSB desktop computer program, refreshing and
    consolidating some computer servers, and improving technical resources for
    continuity of operations.

    ^42DOT IG, Information Security Program: National Transportation Safety
    Board, FI-2007-001 (Washington, D.C.: Oct. 13, 2006).

    NTSB Carries Out Its Transportation Safety Function by Investigating Accidents,
    Issuing Recommendations, and Taking Proactive Steps Outside of Specific
    Accidents

    NTSB has an accident investigation process in which some transportation
    modes have detailed criteria for determining which accidents to
    investigate, while others do not. Although accident investigations are
    sometimes lengthy, NTSB takes steps to ensure that recommendations for
    improving transportation safety are made available to the transportation
    industry before a report is issued. To assist in accident investigations,
    NTSB employs the use of outside sources that provide technical expertise.
    Also, public hearings are used to assist in the investigation process,
    although they are time and resource intensive. Finally, NTSB proactively
    accomplishes its mission by conducting public forums and safety studies.

    NTSB's Use of Risk-Based Criteria to Select Accidents to Investigate is Uneven

    NTSB accomplishes its transportation safety function by conducting
    on-scene investigations of selected accidents in all transportation modes.
    Since its inception in 1966, NTSB has investigated over 134,000
    transportation accidents, over 90 percent of which were aviation. NTSB's
    statutory mandate gives it broad discretion in determining which accidents
    in the nonaviation modes to investigate. Since NTSB lacks the staff
    resources to conduct on-scene investigations of all aviation accidents or
    a large number of nonaviation accidents, certain modal offices have
    adopted additional risk-based guidance for selecting accidents for
    investigation. Figure 9 describes the legislative and other criteria that
    NTSB uses to identify accidents to investigate.

    Figure 9: Legislative, Regulatory, and Other Criteria for Identifying
    Accidents to Investigate, by Mode

    NTSB allocates most of its staff resources to conduct a significant number
    of aviation accident investigations. As mentioned earlier in this report,
    NTSB is required by statute to investigate all domestic civil aviation
    accidents and certain other aviation accidents. However, in 2004, citing a
    severe shortage of regional investigators, the Office of Aviation Safety
    issued a memorandum to investigators intended to manage its aviation
    workload due to the shortage of aviation investigators. The memorandum
    calls for, among other things, more selectivity in which accidents to
    investigate on-scene in order to minimize investigative efforts on
    accidents in which there is minimal safety "payback," equalize regional
    workloads, and reassign some accidents to NTSB headquarters for
    investigation. Even with this guidance, the number of NTSB's staff that
    investigates aviation accidents may limit the resource amounts that NTSB
    can use to investigate accidents in other modes, especially rail, which
    may have broader or more critical safety implications, which we discuss
    later in this report.

    In addition, NTSB investigates general aviation and small aircraft
    accidents that are also investigated by FAA. In some cases, NTSB uses FAA
    investigators and inspectors to leverage its resources.^43 NTSB's size
    prevents it from being on-site for many general aviation investigations;
    therefore, the agency conducts "desk investigations" in which NTSB
    investigators do not go to the scene of the accident to gather information
    but rather correspond with FAA by mail, e-mail, or phone to gather
    information and conduct analyses.

    As with the aviation mode, NTSB is also mandated to investigate certain
    types of transportation accidents in nonaviation modes. NTSB has orders or
    guidelines that define the safety program for each mode and identify the
    types of accidents that are investigated and the procedures for doing so.
    Furthermore, in an attempt to manage resources and ensure the maximum
    safety benefit, the highway office has adopted policies that are within
    the framework of the legislation and board orders and that identify and
    prioritize candidate accidents for investigation. For example, in an
    effort to ensure better use of resources, the highway office has a
    four-tier system to identify accidents for investigation based on the
    severity of the accident and the amount of property damage, among other
    things. This system provides risk-based criteria for the office to
    determine which of the approximately 6 million highway accidents each year
    it will investigate. In contrast, the marine office, which investigates
    significantly fewer accidents than the highway office--in 2005, NTSB,
    investigated 32 highway accidents compared with 3 marine accidents--has
    instituted guidance that provides less restrictive criteria for
    determining which accidents to investigate. For example, the regulations
    and a memorandum of understanding with the Coast Guard require NTSB to
    investigate selected major marine accidents, which include casualties that
    result in the loss of six or more lives or property damage of $500,000 or
    more, while additional guidance calls for investigating accidents with one
    or more fatalities or $75,000 or more in property damage.

    ^43FAA can also conduct separate investigations looking into compliance
    issues with federal aviation laws and regulations. 49 U.S.C. S40113(a).

    In contrast to the highway mode, NTSB does not have documented, risk-based
    criteria for selecting rail, pipeline, and hazardous materials accidents
    to investigate. Board orders for these modes contain the statutory
    language for selecting accidents to investigate but no further criteria.
    As a result, officials from NTSB's rail, pipeline, and hazardous materials
    offices told us that it is difficult to determine which accidents to
    investigate given their resource constraints. They said that the number of
    investigators has decreased since 2000 and that attrition has been a
    significant problem for them because they are losing expertise. Since
    2000, the office experienced a 16 percent decline in the number of
    investigators and technical specialists--the 37 staff filling these
    positions in fiscal year 2000 dropped to 31 at the beginning of fiscal
    year 2007.

    As a result of not having a policy for selecting accidents in these modes,
    the agency lacks assurance and transparency that it is managing resources
    in a manner that ensures a maximum safety benefit. For example, a rail
    stakeholder that we spoke with questioned why NTSB did not investigate
    four railroad accidents in 2006 that resulted in one fatality, several
    injuries, and significant property damage. Moreover, at least three of
    these accidents resulted from collisions, which they identified as a
    recurring problem in the rail industry that NTSB has placed on its "Most
    Wanted List"--which includes those safety recommendations that NTSB has
    designated as critical--meaning that changes are needed to reduce
    transportation accidents and to save lives.^44 According to NTSB
    officials, safety issues that they have already identified, such as those
    on the "Most Wanted List," are a lower priority to investigate than new
    safety issues. While this is a reasonable approach, it is not documented
    policy and clearly has not been communicated to industry or the public.

    ^44To prevent train collisions and overspeed accidents, NTSB's "Most
    Wanted List" includes a recommendation that FRA require automatic control
    systems to override mistakes by human operators.

    In addition, while stakeholders recognize that NTSB lacks resources to
    investigate many rail accidents, they believe that NTSB most often
    investigates only large or controversial rail accidents. For example, of
    the 3,191 railroad accidents that occurred in 2005, NTSB investigated 9.
    By comparison, FRA, with a staff of 435 field inspectors compared to 13
    NTSB railroad investigators, investigated 98 accidents that year. Rail
    stakeholders told us that they believe that there are some "small"
    accidents with root causes and contributing factors that could have
    prevented larger accidents. While these small accidents may not result in
    great human or property loss, they may have significant safety
    implications and serve as forecasts for future accidents, as well as
    providing background data to inform investigators of mitigating
    circumstances in other accidents. As a result, stakeholders are unsure why
    certain accidents are selected for investigation and believe that rail
    accident investigation criteria should be reviewed.

    NTSB Has Taken Steps to Reduce the Potential Negative Consequences of Lengthy
    Investigations

    The length of NTSB investigations can adversely impact transportation
    safety by delaying the final report and any safety recommendations. NTSB,
    recognizing that investigations are lengthy, has processes that address
    transportation safety issues before the release of a report. The initial,
    on-scene phase of the accident investigation, and the subsequent analysis
    of evidence, has taken an average of 1.5 years (or 18 months) to complete.
    Moreover, the average duration of accident investigations has increased
    over the last 10 years. For example, in 1996 the average length of an
    investigation was 410 days, compared with 638 days in 2006. (See fig. 10.)

    Figure 10: Average Duration of Accident Investigations for Which
    Recommendations were Issued, Calendar Years 1996-2006

    There is no specific time line for how long an accident investigation
    should take, according to NTSB; the complexity of the accident dictates
    the time frame for completing the on-scene phase of the investigation. Two
    additional factors also are likely to affect the length of accident
    investigations. First, investigators sometimes need to investigate new
    accidents before completing ongoing investigations. Second, NTSB managers
    and investigators told us that resource constraints are contributing
    factors in how they accomplish their mission. Specifically, rail officials
    said that declining numbers of investigators affect the number of
    accidents that they investigate.

    The potential negative effect of a lengthy accident investigation is that
    a full report outlining details of the accident, including probable causes
    and sometimes safety recommendations, is not issued until the completion
    of the investigation. In certain cases, this may hinder transportation
    safety as recommendations for improvements may be delayed until the report
    is issued. However, NTSB employs two tools to help ensure transportation
    safety in this instance. First, NTSB can issue safety recommendations
    before a report is issued. NTSB designates priority recommendations as
    "urgent." Since 2001, the agency has issued 26 urgent recommendations, of
    which 6 have been implemented.^45 An urgent recommendation outlines
    immediate actions for the transportation industry to take to prevent
    impending loss or damage due to a similar accident. For example, NTSB
    issued urgent recommendations to the Northeast Regional Commuter Railroad
    Corporation to install an automatic train control system and to the
    Washington Metropolitan Area Transit Authority to provide written
    instructions for identifying and responding to emergency train rollback
    situations. Second, during the course of an investigation, investigators
    can also issue suggestions for improvements that can be addressed to a
    variety of entities such as states, private organizations, or
    manufacturers. Once these suggestions have been implemented, they then
    become safety accomplishments. Since fiscal year 2001, NTSB has issued 256
    safety accomplishments, of which over 90 percent have been in the aviation
    mode.

    External Sources Provide Essential Services during Accident Investigations

    Outside experts provide critical assistance to NTSB investigators
    throughout the on-scene phase of an investigation. During the course of an
    investigation when additional support is needed for fact finding or
    technical analysis, NTSB supplements its investigative staff through the
    use of "parties" and outside contractors.^46 "Party" participants are
    individuals, agencies, companies, and associations that can provide
    technical expertise relevant to a specific accident during the
    fact-finding phase. For example, in an aviation accident, the parties to
    the investigation may include the aircraft manufacturer and operators; by
    statute, FAA is always a party to an aviation investigation. While the
    party process may provide technical information that is important for
    determining the cause of an accident, it presents inherent conflicts of
    interest for entities that are both parties in an investigation and
    potential defendants in related litigation. For example, in a commercial
    aviation accident, the principal defendants in litigation for damages are
    likely to be the airline and aircraft manufacturer, who may face liability
    for dozens of deaths. In addition, both entities are likely working with
    NTSB as parties to the investigation.

    ^45Of the 26 urgent recommendations, 21 were aviation, 3 were highway, and
    2 were rail-related.

    ^46NTSB contracts with experts who deal with specific facets of the
    investigation for which NTSB does not need to retain continual expertise.
    For example, following an accident involving casualties, NTSB's Office of
    Transportation Disaster Assistance, which is responsible for providing
    support to victims' families, may contract a team of forensic specialists
    who respond to mass fatality events. These outside contractors are used by
    all modes depending upon the accident and the type of information and
    analysis needed. Since 2004, NTSB has contracted with 10 different
    companies, which provided services such as radiological testing, pipeline
    testing, and report writing, for a total cost of $282,757.

    Despite such challenges, the party system appears to be working well. RAND
    found that the party system works well in that it allows NTSB to leverage
    its resources to provide critical safety information in regard to the
    accident under investigation. In addition, NTSB officials told us that the
    system is an efficient way of gathering and sharing information about the
    accident with investigators and other parties. Also, having multiple
    parties on an investigation offsets concerns of conflict of interest and
    impartiality.

    NTSB May Also Conduct Public Hearings During Investigations, Which Are
    Infrequent and Resource Intensive

    Although public hearings can provide useful information to NTSB
    investigators to assist in the accident investigation and define policy
    issues or emerging areas of transportation safety, they occur infrequently
    because NTSB managers view them as an inefficient use of resources. Public
    hearings are inquiries intended to supplement the facts discovered during
    the on-scene and subsequent follow-up investigation of an accident. They
    are generally held with regard to a major accident in which there is wide
    and sustained public interest, or significant safety issues. They are
    intended to produce comprehensive coverage of all relevant factual data
    and publicly record the substance of all the evidence. Since 1997, NTSB
    has held 29 public hearings, primarily for aviation accidents (see table
    3). Of those 29 hearings, 16 were as a result of an accident, and the
    other 13 were on general transportation safety issues such aviation image
    recorders^47 or pipeline safety. Of the 16 accident hearings, 13 were held
    within 1 year of the accident, and the remaining 3 were held within two
    years of the accident.

    ^47Aviation imaging recorders are crash-protected imaging systems often
    called video recorders on aircraft used in commercial air transportation
    operation.

    Table 3: Number of Public Hearings by Mode, Calendar Years 1997-2006

                                      Rail, pipeline, and hazardous
    Year  Aviation Marine                              materials Highway Total
    1997         1      0                                      0       0     1
    1998         1      1                                      1       2     5
    1999         1      2                                      2       3     8
    2000         2      0                                      1       1     4
    2001         0      0                                      0       0     0
    2002         2      0                                      1       0     3
    2003         1      0                                      0       1     2
    2004         1      0                                      0       0     1
    2005         1      0                                      1       0     2
    2006         2      0                                      0       1     3
    Total       12      3                                      6       8    29

    Source: GAO analysis of NTSB data.

    Note: Calendar year 2006 includes data through August 2006.

    NTSB managers have cited resource constraints as reasons for the limited
    use of public hearings. However, on occasion, board members have voted to
    hold a public hearing despite staff recommendations to the contrary. NTSB
    officials told us that the coordination and preparation of witnesses to
    testify at the hearings requires significant administrative planning and
    logistical organization and that this process can sometimes be costly,
    take resources away from accident investigations, and delay reports.
    However, NTSB was not able to provide data on how much time is spent
    preparing for public hearings because it lacks a full cost accounting
    system. Nonetheless, transportation industry stakeholders felt that
    hearings were valuable for public transparency because they allowed for
    the parties to the investigation to question the witnesses. In an effort
    to reduce travel costs associated with public hearings, in 1999, NTSB
    began holding all public hearings in Washington, D.C., whereas previously
    hearings were held near the site of the accident. In addition, NTSB has
    also begun webcasting public hearings so that individuals interested in or
    associated with the accident may view it without traveling to the hearing.

    Most NTSB Recommendations Are Accepted, but Some Recommendations Are Impractical
    for the Industry to Implement

    NTSB has a good record of making recommendations to improve transportation
    safety and having a large percentage of recommendations implemented. Since
    1996, NTSB has issued 2,417 recommendations, of which 1,647 (or 68
    percent) were closed. Of the closed recommendations, 88 percent have been
    closed out with the agencies having taken acceptable or favorable action
    toward implementation. The remaining 12 percent of closed recommendations
    were closed out with an "unacceptable" status classification. NTSB uses
    the unacceptable classification for situations such as the agency not
    agreeing to implement the recommendation, taking longer to implement than
    NTSB would like, or taking alternative action to meet the intent of the
    recommendation, which NTSB finds unacceptable. (See app. III for further
    information.) The recommendation acceptance rate for closed
    recommendations varies across modes--with rail having the highest
    acceptance rate and marine the lowest--and the overall rate has remained
    relatively high over the last decade. (See fig. 11.) Regarding NTSB's open
    recommendations for this same time period, about 15 percent of NTSB's open
    recommendations are classified with an unacceptable agency response.
    Aviation has the highest percentage of open recommendations with an
    unacceptable response, while pipeline has the lowest. (See fig. 12.)

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

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

    Figure 12: Percentage and Number of Open Recommendations with Unacceptable
    Agency Action Issued During Calendar Years 1996-2006

    Note: For each mode of transportation, the bar shown represents the number
    of recommendations that were open as of June 8, 2006, and have an
    unacceptable action status category assigned by NTSB. The embedded pie
    chart for each mode shows what percentage these unacceptable
    recommendations make up of that mode's total number of open
    recommendations. Calendar year 2006 includes data through June 8, 2006.

    Although there may be several reasons why agencies do not implement some
    NTSB recommendations, cost is a contributing factor. NTSB does not
    determine the costs associated with the benefits of a particular safety
    recommendation. As a result, agencies determine that some recommendations
    are impractical for industry to implement. Some of those recommendations
    that the industry considers impractical are deemed of high importance to
    NTSB, which has placed them on its "Most Wanted List." For example, a
    recommendation from this list that remains open due to an analysis of
    excessive cost by the FAA is to improve audio and data recorders on
    aircraft, based on an original safety recommendation from 1999. FAA
    determined that after an analysis of the benefits of having two systems,
    it was unable to justify the excessive cost that would be incurred in the
    installation of two complete systems and, therefore, this change has not
    been required by FAA.

    While cost may be an important factor for why some recommendations are not
    implemented, agencies also site redundancies that some recommendations may
    cause as a reason for disagreement with the recommendation. For example,
    in 1997, NTSB recommended that FRA require the recording of train crew
    members' voice communications for use in accident investigations. However,
    after review, FRA found that this recommendation was impractical because
    there were already devices in place that would better capture and preserve
    data that would provide information to investigators in an accident
    investigation. For this reason, FRA concluded that the implementation of
    cab voice recorders was not justified and did not accept this
    recommendation.

    The process of closing out or changing recommendations is time consuming
    and paper-intensive and relies on a series of sequential reviews that can
    take months to complete. As a result, resources within NTSB are
    inefficiently used, and federal agencies may be unaware of whether their
    response has been accepted or not accepted by NTSB. In our prior work, we
    recommended that NTSB improve the efficiency of the review process for
    recommendations by computerizing the documentation and implementing
    concurrent reviews. NTSB agreed with this recommendation and would like to
    replace its current process with an automated one. However, they stated
    that their ability to do this will depend on the availability of funds. In
    the meantime, in response to our recommendation, NTSB has created the
    position of Associate Managing Director for Quality Assurance. This
    individual is analyzing the manual review process for changing the status
    of recommendations and is expected to recommend strategies to ensure that
    the process is effective and efficient, according to NTSB officials.

    NTSB Takes Proactive Steps Outside of Specific Accident Investigations

    NTSB complements its accident investigation activities through
    supplemental tools that are not necessarily a part of the accident
    investigation process. Safety studies, public forums, and symposia are
    mechanisms that NTSB uses to gather further information on transportation
    safety. Safety studies consist of research undertaken by NTSB on safety
    issues that may be relevant to more than one accident. They are intended
    to provide improvements in transportation safety by affecting changes to
    policies, programs, and activities of agencies that regulate
    transportation safety. Safety studies also allow NTSB to assess and
    reassess techniques and methods of accident investigation and may result
    in recommendations to reduce the likelihood of recurrence of
    transportation accidents. Since 2000, NTSB conducted four safety studies.
    (See table 4.) The four studies resulted in 41 recommendations addressed
    to FAA and PHMSA. For example, in a 2005 study of risk factors associated
    with general aviation accidents, NTSB recommended that FAA revise guidance
    material associated with pilot weather briefings to include guidance on
    applicable sources of weather information, such as the Internet and
    satellites; NTSB also recommended that FAA develop a means to identify
    pilots whose overall performance history indicates that they are at future
    risk of accident involvement and develop a program to reduce risk for
    those pilots. Industry stakeholders told us they would like NTSB to
    conduct more safety studies, which they believe address NTSB's mission in
    a more proactive way. For the most part, safety studies are initiated at
    the request of NTSB staff, and recent studies have taken between 1 and 3
    years to complete. According to NTSB, the number of safety studies it
    conducts is resource-driven. However, NTSB officials recognize the
    importance of these studies and would like to find ways to make them less
    resource intensive and more effective by decreasing the duration of these
    studies and the resources involved and finding ways to issue
    recommendations prior to completion of the studies.

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

    Year Number of studies  Mode
    2000                 1  Aviation(1)
    2001                 1  Aviation (1)
    2002                 0  Not applicable
    2003                 0  Not applicable
    2004                 0  Not applicable
    2005                 2  Aviation (1), pipeline (1)

    Source: GAO analysis of NTSB data.

    Another method by which NTSB accomplishes its transportation safety
    function is the use of public forums and symposia. Unlike public hearings,
    these deliberations are intended to gather information about safety issues
    affecting all modes of transportation, instead of one specific accident or
    mode. Public forums highlight safety issues that have been a factor in
    past accident investigations and that will perhaps be an issue in the
    future should the transportation industry not take action. NTSB managers
    find that forums and symposia are not as resource intensive or as costly
    as public hearings because they do not require coordination of witnesses,
    parties, technical panels, and court reporters.

    NTSB's Training Center Is Not Cost-Effective; Options Could Increase
    Cost-Effectiveness, but Vacating Space May Be Least-Cost Strategy

    While NTSB staff and other students at the training center have been
    positive about the quality of the courses, NTSB's training center is not
    cost-effective, as the combination of the training center's revenues and
    external training costs avoided by NTSB staff's use of the training center
    do not cover the training center's costs. Training center revenues are
    affected by several factors, including low utilization of the training
    center and the availability of similar courses elsewhere that may reduce
    the number of students interested in training center classes. Furthermore,
    NTSB's courses are already priced at or above market prices, making it
    unlikely that NTSB could raise its course prices, although decreasing
    course prices may attract more students and, thereby, increase total
    revenue. Potential strategies to increase revenues or decrease costs could
    increase the cost-effectiveness of the training center, although vacating
    the space may be the least-cost strategy, even if NTSB had to buy out the
    remaining lease.

    Training Center's Revenues and Avoided Costs Do Not Cover Training Center's
    Costs

    Assessing the financial impact of the training center on NTSB requires
    looking at both the revenues the training center generates and any costs
    that it enables NTSB to avoid, and comparing these revenues and avoided
    costs with the direct costs of the training center. The training center
    generates revenues through tuition fees, subleasing space to other
    agencies for events such as conferences, and contracts with federal
    agencies that would allow them to use training center space for
    "continuity of operations" in emergency situations.

    For the first 2 full years of operation, fiscal years 2004 and 2005,
    NTSB's training center did not generate sufficient revenues to cover the
    costs of providing training, as shown in table 5. As a result, those
    portions of the training center's costs that were not covered by the
    revenues from tuition and other sources--approximately $6.3 million in
    fiscal year 2004 and $3.9 million in fiscal year 2005--were offset by
    general appropriations to the agency. The salaries and other
    personnel-related expenses associated with NTSB investigators and managers
    teaching at the training center, which would be appropriate to include in
    training center costs, are not included in table 5. In addition, NTSB
    lacks a full cost-accounting system that would facilitate doing so. The
    table shows expenses directly associated with the training center and does
    not include an allocation of agencywide supporting services, such as the
    Managing Director's office, IT, human resources, and legal support. Some
    of the expenses during these 2 years were one-time expenses--such as over
    $125,000 for furniture and equipment (included in table 5 as office
    supplies and equipment for fiscal year 2005) and $499,000 to move the
    wreckage of the TWA flight 800 airplane^48 from storage near the crash
    site in New York to the training center (included in the table as
    miscellaneous government contract services in fiscal year 2004). Space
    rental is a fixed annual expense of about $2.5 million. When that fixed
    expense is excluded from training center expenses, the remaining operating
    expenses exceeded revenues by about $3.7 million in fiscal year 2004 and
    about $1.4 million the subsequent year.

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

                                                           Fiscal year Percentage
                                          Fiscal year 2004        2005 difference
    Personnel related                        $1,011,716    $978,591        -3%
    Travel                                      $24,428     $56,912       133%
    Space rental^a                           $2,521,440  $2,500,896        -1%
    Maintenance/repair of buildings            $706,279    $238,203       -66%
    Miscellaneous government contract        $2,204,880    $558,540       -75%
    services
    Office supplies and equipment               $12,939    $153,249     1,084%
    Miscellaneous expenses^b                    $29,320     $28,887        -1%
    Total expenses                           $6,511,002  $4,515,278       -31%
    Earned revenue^c                           $258,760    $634,800       145%
    Overall deficit                         -$6,252,242 -$3,880,478       -38%
    Deficit when space rental expense       -$3,730,802 -$1,379,582       -63%
    is excluded

    Source: GAO analysis of information from NTSB.

    aNTSB leases the training center from George Washington University under a
    20-year lease that will expire in 2021.

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

    cEarned revenue includes imputed fees for NTSB students.

    Other sources of revenue would be needed for NTSB to be able to recover
    the full costs of the training center. For fiscal year 2004, over $12,000
    in revenue (about 5 percent of total revenues) was collected from sources
    other than course fees to cover some of those costs.^49 For fiscal year
    2005, the revenue from other sources increased to over $91,000 (about 14
    percent of total revenues). Other sources of income during these 2 years
    included subleasing space to other organizations, such as the Society of
    Automotive Engineers, George Washington University, and the National
    Association of State Boating Law Administrators for meetings, conferences,
    and boat storage. NTSB determines facility usage fees for subleasing space
    by assessing the square footage of each room, then using that square
    footage to determine what that figure represents in terms of the
    percentage of overall space. This percentage is then valued against the
    lease for the facility, calculated on a per-day basis. Each room and lab
    space, therefore, carries a half day, full day, and weekly value that
    carries a charge reflecting its value, in terms of space, to the overall
    lease, but not in terms of the full cost of the space. In addition, NTSB
    has contracted with two agencies--the Federal Energy Regulatory Commission
    and the U.S. Veterans Affairs Courts--for continuity of operations.
    According to NTSB officials, it has explored this option with other
    organizations but has not found others who will pay a yearly retainer for
    the use of the space.

    ^48The wreckage is used for certain courses.

    ^49In fiscal year 2004, NTSB offered 11 gratis offerings to attract users
    and showcase the facilities. In fiscal year 2005, there were no gratis
    offers as the promotional aspect was no longer needed, according to NTSB.

    However, additional revenues from continuing the current practice of
    subleasing training center space is not likely to cover training center
    costs due to the magnitude of the training center's deficit and because
    the fee structure does not cover the full cost of the space. Furthermore,
    NTSB does not have a business plan or marketing strategy that seeks to
    optimize opportunities for additional revenues. Previously, we recommended
    NTSB develop a comprehensive marketing plan that includes such things as
    outreach to potential users, marketing classroom and conference space, and
    conducting market research for additional curriculum development.^50 In
    response to our recommendation, NTSB has stated that it intends to
    formalize a marketing plan for the training center and make efforts to
    expand the current utilization of the space.

    Another element in the training center's cost-effectiveness is the extent
    to which the training center has allowed NTSB to avoid costs associated
    with external training. However, thus far, the training center has had a
    limited impact on external training costs--of about $1,041,000
    annually--as the majority of students at the training center have been
    non-NTSB staff, and NTSB staff have taken a majority of their training
    courses through external sources. About 20 percent of the training
    center's approximately 1,000 students^51 in fiscal year 2004 were NTSB
    staff, about 14 percent of the 1,400 students in fiscal year 2005 were
    NTSB staff, and about 16 percent of the 1,066 students in fiscal year 2006
    were NTSB staff. During fiscal years 2004 through 2006, about 570 NTSB
    students^52 attended 55 of the 71 class sessions conducted at the training
    center. (See fig. 13.) NTSB is making efforts to have staff more fully
    utilize the facility. In fiscal year 2004, 1 of 18 sessions was only for
    NTSB investigators; in fiscal year 2005, 5 of 31 sessions were only for
    NTSB investigators.^53 However, in fiscal year 2006, none of the 22
    sessions was only for NTSB investigators.

    ^50 [58]GAO-06-801T .

    ^51The total number of students is the sum of the participants in all
    classes. Individuals who attended more than one class at the training
    center were, therefore, counted multiple times.

    Figure 13: Number of NTSB and Non-NTSB Students, Fiscal Years 2004-2006

    NTSB staff receive most of their training from outside the training
    center, which may be due to the training center courses lacking the
    subject matter that they require. Our analysis of staff training requests
    for fiscal year 2006 showed that 97 percent of all training was expected
    to be from external sources and the remaining training from NTSB's
    training center. NTSB staff requested external training being provided by
    organizations that include FAA's Transportation Safety Institute (TSI),
    the University of Southern California, the U.S. Department of Agriculture,
    and Kettering University on subjects such as human factors in aviation
    safety, turbine engine investigation, and automotive design and safety.^54
    Staff training requests also cover other specialties such as helicopter
    training, flight training currency for pilots, technical writing,
    supervisory and management skills, and industry conferences. A majority of
    the 25 investigators and writer-editors with whom we spoke had positive
    views on the quality of training center courses but provided several
    reasons for not taking further courses there. Ten of the 25 investigators
    and writer-editors we interviewed told us that they had taken (or taught)
    courses at the training center and thought the courses were excellent;^55
    none of the investigators and writer-editors had anything negative to say
    about the quality of any training center course. In addition, our review
    of students' course evaluations for fiscal years 2004 and 2005 indicated
    high positive responses. However, none of the NTSB staff we talked with
    had plans to attend training center courses in fiscal year 2007. One
    reason noted for this situation was the remoteness of Ashburn, Virginia,
    from their residences. Another reason was the lack of courses on new
    transportation technologies and the skills and competencies needed by an
    investigator-in-charge. Eight investigators told us that they find
    workshops by manufacturers, such as aircraft and automobile manufacturers,
    more valuable to their work than courses held at the training center.

    ^52Individuals that attend more than one class are counted multiple times.

    ^53These course sessions were Conducting Effective Technical
    Presentations; two sessions each of Media Training and Major Investigation
    Protocol and Processes; and a joint training class with the Federal Bureau
    of Investigation.

    The training center is not utilized more by NTSB staff, in part, because
    the agency has not developed a core curriculum for its staff that could
    then be offered at the training center. The training center only offers
    one course that is required for NTSB's aviation investigator staff---a
    2-week course on aviation accident investigation. There are no refresher
    courses for aviation accident investigation. The Deputy Manager of the
    training center told us that the training center plans to eventually offer
    more internal training covering subjects such as management skills,
    retirement, and computers.^56 However, no milestones or specific plans
    have been established for that effort, and the cost of developing those
    courses has not been estimated. Moreover, even if NTSB were able to
    completely replace external training with courses at the training center
    (an unlikely scenario), avoiding NTSB's current external training costs of
    $1,041,000 annually would not come close to offsetting the training
    center's annual lease costs of $2.5 million.

    ^54Some subjects, such as human factors, are also taught at NTSB's
    training center.

    ^55Our review of course evaluations for fiscal years 2004 and 2005
    indicated high positive responses by students to the training center
    courses. The data lacked information for us to compare evaluations by NTSB
    students and non-NTSB students.

    ^56NTSB is considering contracting out more courses such as these.

    Training Center Revenues Are Affected by Low Utilization, Availability of
    Courses Elsewhere, and Courses at or Above Market Prices

    The training center's revenues are affected by several factors, including
    low utilization, the availability of similar courses elsewhere, and the
    fact that the courses are already at or above market prices. Although
    there is no statutory requirement that NTSB's training center generate
    sufficient revenues to cover its costs, in July 2005, NTSB was encouraged
    in the Senate report accompanying the Fiscal Year 2006 DOT Appropriations
    Act to be more aggressive in imposing and collecting fees to cover the
    costs.^57 To the extent that NTSB maximizes the use of the training
    center, it can produce additional revenues that may help cover costs.
    However, NTSB has not maximized the use of its training center.^58 We
    estimate that, overall, less than 10 percent of the available classroom
    capacity was used during fiscal years 2005 and 2006.^59 Figure 14 shows
    the days in which classroom space was used for 22 class sessions and 22
    other events, such as workshops and seminars by organizations that
    subleased the space during fiscal year 2006. As shown in the figure,
    classroom space was not used at all during October 2005 and March 2006 and
    during November, January, February, and August, classrooms were in use 4
    days or less. In addition, at any given time, no more than three
    classrooms were in use at one time.

    ^57Senate Report 109-109 accompanying Pub. L. No. 109-115, the
    Transportation, Treasury, the Judiciary, Housing and Urban Development,
    and Related Agencies Appropriations Act of 2006.

    ^58The training center facility contains five classrooms (including an
    auditorium); a large area that houses the TWA flight 800 reconstruction,
    aircraft, and other wreckage; eating and lounge areas; and office space
    for six employees who constitute NTSB's Mid-Atlantic Regional Aviation
    Office.

    ^59We excluded federal holidays and the last week in December from our
    analysis because we would not expect space to be used on those days. In
    some cases, courses used multiple classrooms. We estimated one classroom
    was used per course because we lacked specific information on which
    courses used multiple classrooms. To account for that situation, we
    rounded up the percentage of space utilized.

    Figure 14: Utilization of Training Center Classrooms by Classes and Other
    Events, Fiscal Year 2006

    Note: Bars indicate courses or events. For example, two stacked bars
    indicate that two courses or events took place on a particular day.

    The training center's revenues are also affected by limitations associated
    with current course offerings and the fact that NTSB has not identified a
    market niche for its course offerings. Most students at the training
    center are from outside NTSB; however, several factors affect the agency's
    ability to attract additional outside students. The training currently
    offered at the training center is similar to training provided by other
    institutions. FRA, FAA, and PHMSA officials told us that their inspectors
    do not attend NTSB training because similar training is provided in-house
    by DOT's TSI. For example, an FAA inspector told us that new inspectors
    take a basic accident investigation course at TSI and subsequently take
    midcareer follow-up courses there. Furthermore, our comparison of NTSB's
    fiscal year 2006 curriculum with that of several other institutions that
    teach courses on accident investigations showed that other institutions
    offered courses similar to 12 of NTSB's 19 courses. For example, TSI
    offers basic courses on aviation and bus accident investigations, and the
    University of Southern California offers a course on human factors related
    to accident investigations. Moreover, as mentioned previously, NTSB staff
    described choosing external training over NTSB courses because of more
    specialized offerings that are only offered elsewhere, such as workshops
    by aircraft manufacturers.

    NTSB is unlikely to be able to increase revenue by increasing course
    prices, as its courses are already offered at or above market prices.
    While NTSB charges tuition at a level to generally cover the class costs
    (excluding facility costs), charging higher tuition to include facility
    costs would put NTSB at a competitive disadvantage to other institutions
    that provide courses on accident investigations. Currently, NTSB
    determines tuition prices by estimating direct course costs (such as the
    costs for course materials, contracted instructors, and the instructors'
    travel) and dividing that cost by the projected class size. As a result,
    for certain courses, the NTSB training center charges as much or more per
    course than the average cost per course charged by other safety
    institutions, and any additional charges for NTSB's courses could reduce
    the training center's revenues by pricing the courses out of comparable
    range for other transportation safety training institutions. For example,
    the cost of NTSB's Aviation Accident Investigation course for the upcoming
    year is $2,950 for 10 days of instruction. TSI's 8-day course on aviation
    accident investigation currently costs $1,844, and the Southern California
    Safety Institute's similar 11-day course costs $2,875. If enrollment is
    sensitive to the course price, NTSB may be able to increase revenue by
    lowering course prices to increase enrollment. However, NTSB would have to
    compare the change in revenue with the change in cost from the increased
    enrollment.

    Furthermore, NTSB training center's courses are also priced higher than
    comparable courses when measured by cost per student hour, even when the
    fixed annual expense of leasing the facility is not considered as part of
    the cost.^60 For example, NTSB's cost per student hour of $55.71 is
    considerably higher than the $18.64 average cost per student hour of
    TSI's,^61 a fee-for-service organization that provides transit, aviation,
    pipeline, motor carrier, highway safety, hazardous material, and risk
    management training nationally and internationally. If the cost to lease
    training center space, a fixed annual expense of about $2.5 million, were
    divided among the students who now attend the training center, class costs
    would dramatically increase and would be even less competitive with fees
    charged by other institutions for similar courses unless the annual fixed
    cost was offset by revenue from a large influx of additional students. For
    example, if the training center lease cost of $2.5 million was divided
    among the 36,160 student hours in fiscal year 2005, the additional cost
    per student hour would be about $69 for a new total of almost $125 per
    student hour. For NTSB's 10-day Aircraft Accident Investigation course,
    the additional cost per student would be $5,530, increasing the cost to
    the student from $2,950 to nearly $8,500.

    Several Options Could Increase Revenues or Reduce Costs

    To determine a long-term strategy for the training center, options to
    increase revenues or to reduce costs need to be considered. Alternatively,
    it could be determined that the center is not self-sufficient and
    subsidies are necessary. We have summarized various alternatives.

    The first option would involve attempting to increase training center
    revenues through attracting more external students. However, to cover the
    $2.5 million annual cost of NTSB's lease, the training center would have
    to add approximately 44,875 student hours above the approximately 36,000
    student hours in fiscal year 2005. Revenues gained in this manner would be
    offset by increased costs of additional classes and instructors; moreover,
    this option remains unlikely to attract additional DOT students as DOT
    agencies prefer to send students to its own institute (TSI). Officials
    from FRA, FAA, and PHMSA told us that their inspectors do not attend NTSB
    training because TSI provides similar training in-house. Moreover, to the
    extent that NTSB competes with other federal training entities, its
    training center is contrary to the governmentwide initiative to
    consolidate and share services. However, if NTSB were to identify a market
    niche and offer different courses, it could potentially attract and retain
    new students and would not be out-of-step with the governmentwide
    initiative. To attract more external students to the training center, NTSB
    could create unique courses and aggressively market them. A marketing
    study could help NTSB assess the demand for different types of courses.
    Other actions NTSB could take include marketing courses through GSA and
    the U. S. Department of Agriculture's Graduate School and listing the
    availability of training center courses on the GSA Web site,^62 which
    allows GSA to identify training opportunities for personnel in the federal
    aviation community, such as "annual aviation workshops" and "training for
    federal aviation." Other training entities, including TSI, Embry-Riddle
    Aeronautical University, and the Southern California Safety Institute,
    publicize their aviation training on this site.

    ^60We calculated NTSB's cost per student hour by dividing its operating
    costs for fiscal year 2005 of $2,014,382 by its total number of fiscal
    year 2005 student hours--36,160--for a cost per student hour of $55.71.
    TSI has a budget of $10,840,000, and its 581,397 student training hours
    brings its cost per student hour to $18.64. We do not know how the NTSB
    and TSI courses compare in quality because such information is not
    available.

    ^61DOT's TSI was established in 1971 to assist DOT modal administrations
    accomplish their mission essential training requirements.

    Second, our analysis of the training center lease indicates that NTSB has
    the flexibility to use the facility in other ways to increase revenues.
    For example, the lease does not preclude NTSB from subletting unused space
    to other users. Since certain space is already configured as classrooms,
    and the training center is located in an academic setting on George
    Washington University's suburban Virginia campus, it may be possible to
    market space to academic users. NTSB could also potentially sublease the
    entire facility. However, subleasing may not help NTSB to recover training
    center costs.

    In the past, NTSB has subleased portions of the facility and has retained
    resulting funds for their own uses. NTSB maintains that they have specific
    authority to retain these funds rather than depositing them in the General
    Fund of the Treasury.^63 NTSB has stated that when they sublease the
    training center facilities they, as a general principle, require for
    nonfederal entities that the use or user has a relationship to
    transportation safety and/or accident investigation; however, NTSB does
    not require this of federal agencies.

    ^62 [59]www.gsa.gov/aircraftpolicy .

    ^63The Miscellaneous Receipts statute, 31 U.S.C S 3302(b), would require
    the funds to be deposited into the General Fund of the Treasury.

    NTSB has authority under its statue to "negotiate and enter into
    agreements...for the provision of facilities, accident-related and
    technical services or training in accident investigation theory and
    techniques...."^64 NTSB reads the authority for the "provision of
    facilities" as allowing it to sublease space, since that authority is in a
    distinct, independent clause and is not restricted (as are services and
    training) to accident-related purposes. NTSB's reading that the "provision
    of facilities" is not restricted to accident-related purposes is a
    reasonable interpretation given the structure of the statute and the
    absence of any contrary indication in the legislative history.^65 Thus,
    NTSB has authority to enter into agreements for the provision of
    facilities and retain the resulting fees, including those resulting from
    subleasing the NTSB training facility.^66

    Third, NTSB could work to minimize the loss incurred by the training
    center by using the training center to reduce NTSB costs in other areas.
    NTSB has the ability to provide more courses that are geared to NTSB staff
    in order to replace some of the external courses they currently take,
    perhaps at less cost. To attract more internal students, we have
    recommended that NTSB develop a core curriculum and add more classes that
    address the skills and competencies needed by its investigative staff.
    Other actions that NTSB could take to increase internal enrollment at the
    training center include allowing transportation manufacturers to conduct
    company-sponsored symposiums and technical training at the training
    center, which could help NTSB investigators keep up with new technologies
    and offering more internal training on subjects such as management skills,
    retirement, and computers. Attracting more internal students would not
    increase revenues for NTSB but would lower its external training costs.

    Fourth, NTSB is not precluded by its training center lease or its lease
    for headquarters space in Washington, D.C., from relocating some
    headquarters staff to the Virginia facility. The lease for the office
    space in Washington, D.C., expires in October 2010. Such a move, however,
    would incur one-time costs that include relocating staff, moving furniture
    and equipment, reconfiguring space and utilities, as well as recurring
    travel costs for staff that must travel between the two locations. Such
    costs would have to be weighed against the reduced cost of leasing less
    space in Washington, D.C. Moreover, the desirability of working at this
    location would also have to be considered. Some staff told us they do not
    attend classes at the training center because of its undesirable location.

    ^6449 U.S.C. S 1113(b)(1)(I).

    ^65While the legislative history of this provision demonstrates that it
    was amended during reauthorization to address NTSB's authority to enter
    into agreements to provide accident-related training and services to
    foreign governments, there is nothing to elucidate the purposes for the
    provision of facilities.

    ^66NTSB additionally asserts that 49 U.S.C. S 1118(c) grants them specific
    authority to retain funds resulting from subleases. Because 49 U.S.C. S
    1113(b)(1)(I) specifically provides for the provision of facilities, it is
    consequently determinative of NTSB's authority in this instance rather
    than 49 U.S.C. S1118(c) where no such specific provision exists. Thus, it
    is unnecessary to address the issue of whether a sublease is a "service"
    under S 1118(c)(2).

    At this time, there is very little difference in the base cost of the
    training center lease and the headquarters lease at L'Enfant Plaza.
    Specifically, the headquarters lease requires an additional expense of
    real estate taxes at about $3 per square foot since the lease is through a
    privately-owned business, while the training center is leased through a
    nonprofit organization, which is exempt from those taxes. Upon renewal in
    fiscal year 2011, the cost of the downtown lease could increase or
    decrease, but that is unknown. Furthermore, the costs of relocation could
    equal or exceed the savings that NTSB might realize by moving some staff
    to the training center and renting less space in Washington, D.C. For
    example, the training center is currently configured as 4 classrooms and
    an auditorium so an immediate cost would be new construction to configure
    office space. Other costs could include computer and phone networks,
    relocating staff, moving furniture and laboratory and other equipment. We
    have recommended that NTSB conduct a study to determine the costs and
    feasibility of moving certain functions from headquarters to the training
    center.^67

    A fifth option to reduce costs would be to buy out the lease and vacate
    the space. Considering the severe budget environment and the projection
    that NTSB courses will most likely never cover training center costs, this
    may be the least-cost strategy. NTSB does not have a cancellation clause
    in the lease. Lack of a cancellation clause is not unusual because it
    allows for a lower monthly payment for the agency, but it also precludes
    NTSB from freeing up these funds for any other use during the life of the
    lease. Since there is no cancellation clause in the lease, NTSB may have
    to pay the remainder of the 20-year lease should it vacate the facility,
    which could amount to about $2.5 million annually through 2021 (a total
    cost of $42.5 million). Some additional costs would be incurred to move
    training center and regional office staff from the training center
    facility to NTSB's headquarters office. This option would eliminate the
    possible yearly cost of several million dollars (the current deficit) and
    allow the money to be used for other purposes. For example, if the funds
    currently going to the training center were used for NTSB's investigations
    and investigative staff, they would more directly support NTSB's mission.
    We estimate that the net expenses of the training center, including the
    cost of the lease, totaling $3,880,478 in fiscal year 2005 could fund over
    25 additional investigative positions each year.

    ^67 [60]GAO-06-801T .

    Conclusions

    NTSB's progress in following some leading management practices, such as
    correcting some computer security vulnerabilities, developing a detailed
    staffing plan, and improving communications from senior management to
    staff, are positive steps in ensuring that the agency's management is
    designed to support its mission. In addition, NTSB's steps toward
    responding to our recent recommendations regarding leading management
    practices in areas such as strategic planning and communication are
    further positive steps. However, key gaps in NTSB's management practices
    remain. The continued lack of comprehensive plans and policies in the
    areas of IT, knowledge management, strategic human capital management, and
    certain acquisition practices suggest that NTSB is still not ensuring that
    its management of these areas is aligned to fully and effectively support
    its mission.

    Since NTSB lacks the resources to investigate all accidents, ensuring that
    it performs investigative activities with the greatest transportation
    safety payoff is also critical to its ability to effectively support its
    mission. While NTSB's investigative activities contain many strong
    elements, we identified some limitations that make it difficult for NTSB
    to ensure it is using its resources as wisely as possible. Specifically,
    NTSB's lack of risk-based criteria for investigations in some modes
    reduces its assurance it is using its resources effectively. Furthermore,
    when criteria exist, they are sometimes included in an interoffice
    memorandum, rather than in a transparent policy document, such as a board
    order. In addition, NTSB's limited use of safety studies (only four in the
    past 6 years) to proactively examine and highlight safety issues may limit
    the effectiveness of its work on behalf of improving overall
    transportation safety.

    Finally, NTSB is facing several challenges related to the costs of its
    training center. First, although NTSB has identified the fact that it is
    in violation of the Anti-Deficiency Act because it is making lease
    payments for the training center annually when it should have been funded
    from its budget authority in fiscal year 2001, it does not have the
    resources to correct this deficiency. Second, NTSB is missing
    opportunities to make the training center cost-effective. Without a
    comprehensive business plan, NTSB will likely be unable to efficiently
    attract users who would help pay the ongoing costs of the facility.
    However, in the final analysis, NTSB may have difficulty increasing
    revenues or decreasing external training costs enough to ever fully offset
    the training center's costs. It is, therefore, important to consider the
    option of buying out the lease and vacating the center entirely when
    considering how best to proceed.

    Recommendations for Executive Action

    To improve the efficiency of agency operations, we recommend that the
    Chairman of the National Transportation Safety Board take the following
    five actions:

               o To improve agency performance in the key management areas of IT,
               knowledge management, and human capital management, NTSB should
               develop plans or policies for IT and knowledge management and
               develop a strategic human capital plan that is linked to its
               overall strategic plan. The human capital plan should include
               strategies on staffing, training, diversity management, and
               recruitment and retention. The IT plan should include a strategy
               to guide IT acquisitions.

               o To make the most effective use of its investigation resources
               and increase transparency, NTSB should develop orders for all
               transportation modes that articulate risk-based criteria for
               determining which accidents would provide the greatest safety
               benefit to investigate or, in the case of aviation accidents,
               explain which accidents are investigated at the scene, or
               remotely, in a limited manner.

               o To be more proactive in identifying and correcting safety
               problems before accidents occur, NTSB should increase its
               utilization of safety studies.

               o NTSB should develop a business plan to increase the utilization
               of its training center or vacate it and submit the plan to
               Congress. As part of this effort, NTSB should determine the costs
               and feasibility of alternative actions such as adding more courses
               for NTSB staff, moving headquarters staff to the center,
               subleasing space to other entities, or buying out the lease.

               o NTSB should identify and implement actions to correct its
               violation of the Anti-Deficiency Act and bring the agency in
               compliance with the act. These actions could include obtaining a
               deficiency appropriation for the full costs of the lease,
               renegotiating or terminating the training center lease so that it
               complies with the Anti-Deficiency Act, or obtaining authority to
               obligate lease payments using annual funds over the term of the
               lease.

    			  Agency Comments

               We provided a draft of this report to NTSB for their review and
               comment. The agency provided written comments (see app. IV). NTSB
               agreed with our recommendations and provided technical
               clarifications, which we incorporated into this report.

               As agreed with your offices, unless you publicly announce the
               contents of this report earlier, we plan no further distribution
               until 8 days from the report date. At that time, we will send
               copies of this report to the Chairman of the National
               Transportation Safety Board and interested congressional
               committees. We also will make copies available to others upon
               request. In addition, the report will be available at no charge on
               the GAO Web site at [61]http://www.gao.gov .

               If you or your staff have any questions about this report, please
               contact me at (202) 512-2834 or dillinghamg@gao.gov. Contact
               points for our Offices of Congressional Relations and Public
               Affairs may be found on the last page of this report. GAO staff
               who made major contributions to this report are listed in appendix
               V.

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

    			  Appendix I: Scope and Methodology

               To determine the extent to which the National Transportation
               Safety Board (NTSB) is following leading practices in selected
               management areas, we reviewed past GAO work on leading management
               practices in the areas of strategic planning, human capital
               management, communications, acquisition management, financial
               accountability and control, information technology, and knowledge
               management. We did not evaluate NTSB's performance in the area of
               capital decision making because the agency does not have a large
               amount of either capital assets or capital acquisitions. With
               assistance from GAO specialists in the functional areas, we
               assessed whether NTSB was mostly following the practices (plans or
               policies for all or nearly all practices have been developed and
               implemented properly), partially following them (plans or policies
               are in place and implemented properly for some practices), or
               minimally following them (plans or policies are lacking for all or
               nearly all practices). We reviewed the results of the Office of
               Personnel Management's (OPM) 2004 Federal Human Capital Survey for
               NTSB in the areas of recruitment, staff development and retention,
               training, communications, and knowledge management. OPM conducted
               the survey during the fall 2004. The survey included 88 items that
               measured federal employee perceptions about how effectively
               agencies are managing their workforces. For more information about
               the 2004 survey, see http://www.fhcs2004.opm.gov/. On the basis of
               our examination of the OPM data and review of prior GAO work
               concerning survey design, administration, and processing, we
               determined that the data were sufficiently reliable for the
               purpose of our review.

               We reviewed recommendations made by the RAND Corporation^1 and
               Booz Allen Hamilton^2  and NTSB's responses to those
               recommendations. Both studies set forth recommendations aimed at
               strengthening NTSB's ability to carry out its safety mission. We
               interviewed current and former NSTB board members, senior
               officials, and division managers and selected investigators and
               writer-editors regarding their experience with those practices at
               NTSB and their perceptions of the effectiveness of those
               practices. We randomly selected 17 of the 203 investigators and 8
               writer-editors roughly evenly across NTSB's four modal offices.
               The views of these particular individuals are not representative
               of all NTSB investigators and writer-editors. We also determined
               NTSB's response to recommendations made by the Department of
               Transportation's Inspector General. We reviewed NTSB documents,
               including strategic, staffing, and performance management plans;
               management advisory e-mails; information regarding the current
               staffing levels; and employees' training plans for 2006.

               To determine the extent to which NTSB accomplishes its accident
               investigation function, develops accident investigation reports,
               and closes safety recommendations in an efficient manner, we
               reviewed policy guidance, including orders, investigative manuals
               and data on the level of current and past investigation activity.
               Additionally, we reviewed studies by the RAND Corporation and Booz
               Allen Hamilton that examined NTSB's investigation process and
               determined the extent to which the agency had implemented their
               recommendations. We interviewed NTSB managers and staff mentioned
               previously, as well as industry and government stakeholders,
               including federal agencies that receive NTSB recommendations;
               aviation, rail, marine, and highway associations; and
               transportation safety advocacy groups (see table 6). We examined
               data on recommendations acceptance rates and closeout status from
               NTSB's recommendation database, and we determined that the data
               were sufficiently reliable for the objectives of this review.

               Table 6: Entities Interviewed by GAO

    			  Type                            Name of entity
    Federal agency                  Federal Aviation Administration
                                       Federal Motor Carrier Safety
                                       Administration
                                       Federal Railroad Administration
                                       National Highway Traffic Safety
                                       Administration
                                       Pipeline and Hazardous Materials Safety
                                       Administration
                                       U.S. Coast Guard
    Industry or safety organization AFL-CIO
                                       Airline Pilots Association
                                       Air Transport Association
                                       American Association of Railroads
                                       Association of Flight Attendants
                                       Brotherhood of Locomotive Engineers and
                                       Trainmen
                                       Brotherhood of Railroad Signalmen
                                       Commercial Vehicle Safety Alliance
                                       International Organization of Masters,
                                       Mates, and Pilots
                                       Maritime Institute for Research and
                                       Industrial Development
                                       Operation Lifesaver
                                       Regional Airline Association
                                       Transit Workers Union of America AFL-CIO
                                       Transportation Communications
                                       International Union
                                       United Transportation Union

               Source: GAO.

               To analyze safety recommendations issued recently by NTSB, we
               analyzed a data extract from NTSB's safety recommendations
               database for recommendations issued from October 1, 1995, and
               forward. A list of the data fields we requested is located in
               table 7. From the data NTSB provided, we determined the number of
               safety recommendations issued by year and by mode of
               transportation, as well as the number of accident investigations
               that yielded these recommendations. We determined the percentages
               of recommendations by mode that are open and closed, and also the
               "acceptance" rate by mode of closed recommendations only.

               Table 7: Safety Recommendation Data Fields Analyzed

    			  Field                 Definition
    Mode                  Mode of transportation, such as aviation, highway,
                             marine, pipeline, or rail
    Recommendation number Number assigned by NTSB to distinguish safety
                             recommendations
    Status                Status of the recommendation, such as open or closed
                             and whether the addressee for the recommendation is
                             taking acceptable or unacceptable action towards its
                             implementation
    Accident date         Date of the accident associated with the safety
                             recommendation
    Date issued           Date the safety recommendation was issued by NTSB to
                             addressee(s)
    Date closed           Date NTSB closed the recommendation
    Addressee             Agency or organization that received the safety
                             recommendation from NTSB
    Addressee status      Status of a specific addressee's response to NTSB's
                             recommendation

               Source: NTSB.

               To determine the extent to which NTSB's training center is a
               cost-effective investment and how it could be more cost-effective,
               we reviewed financial data on NTSB's training center, including
               the revenues and expenses for fiscal years 2004 and 2005. We
               reviewed the course curriculum of the training center and compared
               it with classes offered by the Department of Transportation's
               (DOT) Transportation Safety Institute, Embry-Riddle Aeronautical
               University, the University of Southern California, and the
               Southern California Safety Institute. We examined data on the
               student makeup of training center classes and analyzed data on the
               preparatory and teaching time used by NTSB investigators who
               taught at the training center. We interviewed NTSB investigators,
               writer-editors, and managers and senior officials at DOT's modal
               administrations regarding their current and planned use of the
               training center. We also examined the subleasing of NTSB's space
               for fiscal years 2004 through 2006, and examined the lease for the
               training center to determine how NTSB may utilize the space.
               Finally, we examined the Anti-Deficiency Act violation related to
               the lease agreement for the NTSB training center and reviewed
               legislation for corrective action.

               We conducted our review from December 2005 to November 2006 in
               accordance with generally accepted government auditing standards.

    ^1RAND Institute for Civil Justice, Safety in the Skies: Personnel and
    Parties in NTSB Accident Investigations (Santa Monica, CA.: 2000).

    ^2Booz Allen Hamilton, NTSB Organizational Process and Efficiency Study
    (Washington, D.C.: Aug. 12, 2004).

    			  Appendix II: Prior GAO Recommendations to NTSB

               Based on our ongoing work as of May 2006, to improve the
               efficiency of agency operations we recommended the Chairman of the
               National Transportation Safety Board take the following eight
               actions:^1

               o 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.

               o Develop a full cost-accounting system that would track the
               amount of time employees spend on each investigation and in
               training.

               o 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.

               o 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.

               o Improve the efficiency of the review process for changing the
               status of recommendations by computerizing the documentation and
               implementing concurrent reviews.

               o Develop a comprehensive marketing plan for the training center.
               The plan should consider such things as outreach to potential
               users, working with the U. S. Department of Agriculture's Graduate
               School and the General Services Administration to market it as
               classroom and conference space, and conducting market research for
               additional curriculum development. If ethical and
               conflict-of-interest issues can be addressed, the plan should also
               consider options for allowing transportation manufacturers to
               conduct company-sponsored symposia and technical training at the
               facility, which would benefit NTSB investigators in keeping up
               with new technologies. In addition, the plan should consider the
               feasibility of subleasing a portion of the training center's
               space.

               o Develop core investigator curriculum for each mode and maximize
               the delivery of that training at the training center.

               o Conduct a study to determine the costs and feasibility of moving
               certain functions from headquarters to the training center in
               preparation for the renegotiation of the headquarters lease, which
               expires in fiscal year 2011.

    ^1 [62]GAO-06-801T .

    Appendix III: Additional Analysis of NTSB Safety Recommendations Data

    Figure 15: Number of Recommendations by Mode of Transportation and by Year
    Issued, Calendar Years 1996-2006

    Note: NTSB issued a total of 2,417 safety recommendations from January 1,
    1996, through June 8, 2006. Calendar year 2006 includes data through June
    8, 2006.

    Figure 16: Number of Accident Investigations with Safety Recommendations,
    Calendar Years 1996-2006

    Note: A total of 443 accident investigations resulted in safety
    recommendations. Calendar year 2006 includes data through June 8, 2006.

    Figure 17: Number of Investigations Completed by Mode, Calendar Years
    1996-2006

    Note: A total of 443 investigations that resulted in safety
    recommendations were completed from January 1, 1996, through June 8, 2006.
    Calendar year 2006 includes data through June 8, 2006.

    [This page left intentionally blank]

    Figure 18: Average Investigation Duration by Mode, Calendar Years
    1996-2006

    Note: A total of 443 investigations that resulted in safety
    recommendations were completed from January 1, 1996, through June 8, 2006.
    There were no pipeline investigations completed from January 1, 2005,
    through June 8, 2006, that resulted in safety recommendations. Calendar
    year 2006 includes data through June 8, 2006.

    Table 8: Number and Percentage of NTSB Safety Recommendations with Closed
    Acceptable, Closed Unacceptable, and Open Status by Mode, for
    Recommendations Issued Calendar Years 1996-2005

                                                    Year issued
    Mode     Status        1996   1997  1998   1999  2000  2001  2002   2003  2004   2005
    Aviation Closed         140    105    91     60    90    50    21     22     6      2
             acceptable
                          (78%)  (83%) (68%)  (70%) (63%) (61%) (53%)  (29%)  (8%)   (6%)
             Closed          28     15    24      9    13     0     1      0     2      0
             unacceptable
                          (16%)  (12%) (18%)  (10%)  (9%)  (0%)  (3%)   (0%)  (3%)   (0%)
             Open            11      6    19     17    41    32    18     54    66     33

                           (6%)   (5%) (14%)  (20%) (28%) (39%) (45%)  (71%) (89%)  (94%)
             Total          179    126   134     86   144    82    40     76    74     35

                           100%   100%  100%   100%  100%  100%  100%   100%  100%   100%
    Highway  Closed          39     30    33     39    14    11    15      8    11      2
             acceptable
                          (66%)  (77%) (67%)  (55%) (42%) (30%) (33%)  (25%) (23%)   (6%)
             Closed           6      1     5      6     0     0     0      0     0      0
             unacceptable
                          (10%)   (3%) (10%)   (8%)  (0%)  (0%)  (0%)   (0%)  (0%)   (0%)
             Open            14      8    11     26    19    26    30     24    37     30

                          (24%)  (21%) (22%)  (37%) (58%) (70%) (67%)  (75%) (77%)  (94%)
             Total           59     39    49     71    33    37    45     32    48     32

                           100%   101%   99%   100%  100%  100%  100%   100%  100%   100%
    Marine   Closed          14     54    83     20    26    18    16      0     1      2
             acceptable
                          (74%)  (86%) (66%)  (91%) (72%) (78%) (52%)   (0%) (25%)  (13%)
             Closed           5      7    32      0     1     0     2      0     0      0
             unacceptable
                          (26%)  (11%) (25%)   (0%)  (3%)  (0%)  (6%)   (0%)  (0%)   (0%)
             Open             0      2    11      2     9     5    13      1     3     13

                           (0%)   (3%)  (9%)   (9%) (25%) (22%) (42%) (100%) (75%)  (87%)
             Total           19     64   126     22    36    23    31      1     4     15

                           100%   100%  100%   100%  100%  100%  100%   100%  100%   100%
    Pipeline Closed          22      5    61      8    21     3     3      2     6      0
             acceptable
                          (76%) (100%) (82%)  (67%) (81%) (75%) (60%)  (50%) (43%)   (0%)
             Closed           7      0    11      2     3     0     0      0     0      0
             unacceptable
                          (24%)   (0%) (15%)  (17%) (12%)  (0%)  (0%)   (0%)  (0%)   (0%)
             Open             0      0     2      2     2     1     2      2     8      5

                           (0%)   (0%)  (3%)  (17%)  (8%) (25%) (40%)  (50%) (57%) (100%)
             Total           29      5    74     12    26     4     5      4    14      5

                           100%   100%  100%   101%  101%  100%  100%   100%  100%   100%
    Railroad Closed          64     59    63     61    11    18    14      9     1      2
             acceptable
                          (97%)  (87%) (93%) (100%) (65%) (72%) (45%)  (39%)  (8%)   (9%)
             Closed           2      3     4      0     0     0     0      1     0      0
             unacceptable
                           (3%)   (4%)  (6%)   (0%)  (0%)  (0%)  (0%)   (4%)  (0%)   (0%)
             Open             0      6     1      0     6     7    17     13    11     20

                           (0%)   (9%)  (1%)   (0%) (35%) (28%) (55%)  (57%) (92%)  (91%)
             Total           66     68    69     61    17    25    31     23    12     22

                           100%   100%  100%   100%  100%  100%  100%   100%  100%   100%

    Source: GAO analysis of NTSB data.

    Note: A total of 2,333 recommendations were issued from 1996 through 2005.
    Percentages do not always total to 100 due to rounding.

    Figure 19: Percentage of Safety Recommendations Open for at Least 5 Years,
    by Mode

    Note: Recommendations were issued calendar years 1995-2001.

    Appendix IV: Comments from the National Transportation Safety Board

    Appendix V: GAO Contact and Staff Acknowledgments

    GAO Contact

    Gerald L. Dillingham, Ph.D., (202) 512-2834, or dillinghamg@gao.gov

    Staff Acknowledgments

    In addition to the contact named above, Teresa Spisak, Assistant Director;
    Maren McAvoy; Lauren Calhoun; Eric Fielding; Colin Fallon; Dave Hooper;
    Tom Keightley; Ayeke Messam; Josh Ormond; Jena Whitley; and Alwynne Wilbur
    made significant contributions to this report.

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    Highlights of GAO-07-118, a report to congressional requesters

    November 2006

    NATIONAL TRANSPORTATION SAFETY BOARD

    Progress Made, Yet Management Practices, Investigation Priorities, and
    Training Center Use Should Be Improved

    The National Transportation Safety Board (NTSB) plays a vital role in
    advancing transportation safety by investigating accidents, determining
    their causes, and issuing safety recommendations. To support its mission,
    NTSB's training center, which opened in 2003, provides training to NTSB
    investigators and others. It is important that NTSB use its resources
    efficiently to carry out its mission. GAO was asked to examine the extent
    to which NTSB follows leading management practices, how NTSB carries out
    its transportation safety function, and the extent to which NTSB's
    training center is cost-effective, including potential options for
    improving the center's cost-effectiveness. GAO reviewed NTSB documents and
    data concerning management practices and accident investigations,
    interviewed relevant NTSB and other federal officials, and evaluated
    NTSB's management practices based on leading practices identified in prior
    work.

    [86]What GAO Recommends

    GAO recommends that NTSB fully implement leading management practices,
    develop risk-based criteria for determining which accidents to
    investigate, increase its utilization of safety studies, determine whether
    to develop a business plan to increase the utilization of its training
    center or vacate it, and take steps to rectify its violation of the
    Anti-Deficiency Act. NTSB agreed with the recommendations.

    While NTSB has recently made progress in following leading management
    practices, its overall use of leading management practices in the seven
    areas GAO examined was either minimal or partial. NTSB minimally follows
    leading practices in strategic planning, information technology, and
    knowledge management. NTSB partially follows leading practices in human
    capital management, communications, acquisition management, and financial
    accountability and control. For example, regarding human capital
    management, NTSB developed a detailed staffing plan. However, the agency
    lacks a strategic training plan and a diversity management strategy, which
    are important for ensuring that an organization has strategies for
    achieving the appropriate mix of skills to achieve its mission. In
    addition, while NTSB follows some leading practices for financial
    management, it is noncompliant with the Anti-Deficiency Act because it did
    not obtain budget authority for the net present value of the entire
    20-year lease for its training center lease obligation at the time the
    lease agreement was signed in 2001.

    NTSB carries out its transportation safety function by selecting which
    accidents to investigate, investigating accidents and issuing
    recommendations, and taking proactive steps outside of specific accidents.
    For some transportation modes, NTSB has risk-based criteria for selecting
    which accidents to investigate, while for others it does not. Such
    criteria are important to ensure NTSB is using its resources to achieve a
    maximum safety benefit, particularly because, by statute, NTSB must
    allocate a large proportion of its resources to investigating aviation
    accidents, which may reduce the number of staff that NTSB can use to
    investigate accidents in other modes that may have critical safety
    implications. To its credit, although accident investigations are
    sometimes lengthy, NTSB issues urgent recommendations during the course of
    an investigation. In addition, NTSB proactively carries out its mission by
    conducting safety studies to consider issues that may be relevant to more
    than one accident. Safety studies, which sometimes result in
    recommendations, may also reduce the likelihood of recurrence of
    transportation accidents. Over the last 6 years, NTSB has conducted four
    safety studies. Industry stakeholders stated they would like NTSB to
    conduct more safety studies.

    NTSB's training center is not cost-effective, as the combination of the
    training center's revenues and external training costs avoided by NTSB
    staff's use of the facility do not cover the center's costs. In fiscal
    year 2005, costs exceeded revenues by $3.9 million. Furthermore, the
    training center has had a limited impact on avoiding external training
    costs, as the majority of NTSB staff training occurs externally. Potential
    strategies to increase revenues or decrease costs could increase the
    cost-effectiveness of the training center; however, vacating the space may
    be the least-cost strategy.

    References

    Visible links
      42. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      43. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      44. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      45. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      46. http://www.gao.gov/cgi-bin/getrpt?GAO-03-488
      47. http://www.gao.gov/cgi-bin/getrpt?GAO-04-546G
      48. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      49. http://www.gao.gov/cgi-bin/getrpt?GAO-03-2
      50. http://www.gao.gov/cgi-bin/getrpt?GAO-02-373SP
      51. http://www.gao.gov/cgi-bin/getrpt?GAO-05-762
      52. http://www.gao.gov/cgi-bin/getrpt?GAO-05-585
      53. http://www.gao.gov/cgi-bin/getrpt?GAO-05-90
      54. http://www.gao.gov/cgi-bin/getrpt?GAO-03-669
      55. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      56. http://www.gao.gov/cgi-bin/getrpt?GAO-01-1032
      57. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-134
      58. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      59. http://www.gsa.gov/aircraftpolicy
      60. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      61. http://www.gao.gov/
      62. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
      63. http://www.gao.gov/cgi-bin/getrpt?GAO-06-831
      64. http://www.gao.gov/cgi-bin/getrpt?GAO-05-927
      65. http://www.gao.gov/cgi-bin/getrpt?GAO-05-325SP
      66. http://www.gao.gov/cgi-bin/getrpt?GAO-05-90
      67. http://www.gao.gov/cgi-bin/getrpt?GAO-04-594T
      68. http://www.gao.gov/cgi-bin/getrpt?GAO-04-546G
      69. http://www.gao.gov/cgi-bin/getrpt?GAO-04-49
      70. http://www.gao.gov/cgi-bin/getrpt?GAO-04-39
      71. http://www.gao.gov/cgi-bin/getrpt?GAO-03-1166T
      72. http://www.gao.gov/cgi-bin/getrpt?GAO-03-669
      73. http://www.gao.gov/cgi-bin/getrpt?GAO-03-612T
      74. http://www.gao.gov/cgi-bin/getrpt?GAO-03-488
      75. http://www.gao.gov/cgi-bin/getrpt?GAO-03-2
      76. http://www.gao.gov/cgi-bin/getrpt?GAO-02-373SP
      77. http://www.gao.gov/cgi-bin/getrpt?GAO-01-872T
      78. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-134
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