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

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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 [email protected]. 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 [email protected]

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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(540130)

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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
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  43. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
  44. http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T
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  49. http://www.gao.gov/cgi-bin/getrpt?GAO-03-2
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  59. http://www.gsa.gov/aircraftpolicy
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  63. http://www.gao.gov/cgi-bin/getrpt?GAO-06-831
  64. http://www.gao.gov/cgi-bin/getrpt?GAO-05-927
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  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
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  77. http://www.gao.gov/cgi-bin/getrpt?GAO-01-872T
  78. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-134
*** End of document. ***