Chemical Safety Board: Improvements in Management and Oversight
Are Needed (22-AUG-08, GAO-08-864R).
The principal role of the Chemical Safety and Hazard
Investigation Board (CSB) is to investigate accidental releases
of regulated or extremely hazardous substances to determine the
conditions and circumstances that led to the accident and to
identify the cause or causes so that similar accidents might be
prevented. Accidental releases of these toxic and hazardous
chemicals occur frequently and often have serious consequences.
CSB reported to Congress that the agency received notification of
approximately 900 chemical accidents in calendar year 2007, and
that 31 of these accidents were serious or even fatal events that
warranted the commitment of CSB investigators. CSB began
operating in 1998 as an independent agency created under the
Clean Air Act Amendments of 1990. The act directs CSB to (1)
investigate and report on the cause or probable cause of any
accidental chemical releases from stationary sources resulting in
a fatality, serious injury, or substantial property damages; (2)
make recommendations to reduce the likelihood or consequences of
accidental chemical releases and propose corrective measures; and
(3) establish regulations for reporting accidental releases. The
agency publishes investigative reports and issues safety studies
and videos to help prevent future accidents. Congress modeled CSB
after the National Transportation Safety Board (NTSB), which has
a similar public safety mission. Like NTSB, CSB has no
enforcement authority and a limited regulatory role. As outlined
in the authorizing statute, CSB is to be managed by a five-member
board. Currently the board has one vacancy. CSB received an
appropriation of $9.4 million for fiscal year 2008 and had 39
staff as of January 30, 2008.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-08-864R
ACCNO: A83716
TITLE: Chemical Safety Board: Improvements in Management and
Oversight Are Needed
DATE: 08/22/2008
SUBJECT: Accident prevention
Accountability
Chemical accidents
Data collection
Environmental monitoring
Federal regulations
Hazardous substances
Independent agencies
Internal controls
Investigations by federal agencies
Quality control
Regulatory agencies
Reporting requirements
Risk management
Safety regulation
Safety standards
Strategic planning
Toxic substances
Policies and procedures
******************************************************************
** This file contains an ASCII representation of the text of a **
** GAO Product. **
** **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced. Tables are included, but **
** may not resemble those in the printed version. **
** **
** Please see the PDF (Portable Document Format) file, when **
** available, for a complete electronic file of the printed **
** document's contents. **
** **
******************************************************************
GAO-08-864R
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to [email protected].
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
GAO-08-864R:
United States Government Accountability Office:
Washington, DC 20548:
August 22, 2008:
Congressional Committees:
Subject: Chemical Safety Board: Improvements in Management and
Oversight Are Needed:
The principal role of the Chemical Safety and Hazard Investigation
Board (CSB) is to investigate accidental releases of regulated or
extremely hazardous substances to determine the conditions and
circumstances that led to the accident and to identify the cause or
causes so that similar accidents might be prevented.[Footnote 1]
Accidental releases of these toxic and hazardous chemicals occur
frequently and often have serious consequences. CSB reported to
Congress that the agency received notification of approximately 900
chemical accidents in calendar year 2007, and that 31 of these
accidents were serious or even fatal events that warranted the
commitment of CSB investigators.
CSB began operating in 1998 as an independent agency created under the
Clean Air Act Amendments of 1990. The act directs CSB to (1)
investigate and report on the cause or probable cause of any accidental
chemical releases from stationary sources resulting in a fatality,
serious injury, or substantial property damages; (2) make
recommendations to reduce the likelihood or consequences of accidental
chemical releases and propose corrective measures; and (3) establish
regulations for reporting accidental releases. The agency publishes
investigative reports and issues safety studies and videos to help
prevent future accidents. Congress modeled CSB after the National
Transportation Safety Board (NTSB), which has a similar public safety
mission.[Footnote 2] Like NTSB, CSB has no enforcement authority and a
limited regulatory role. As outlined in the authorizing statute, CSB is
to be managed by a five-member board. Currently the board has one
vacancy. CSB received an appropriation of $9.4 million for fiscal year
2008 and had 39 staff as of January 30, 2008.
In 2000, Congress asked GAO to review CSB's effectiveness in carrying
out its mission. In our report, Chemical Safety Board: Improved
Policies and Additional Oversight Are Needed (GAO/RCED-00-192),
[Footnote 3] we cited problems with CSB's governance, management,
policies, and procedures. Among other things, we recommended that CSB
obtain the services of an existing office of inspector general (IG).
Since fiscal year 2001, three IGs--from the Federal Emergency
Management Agency (FEMA), the Department of Homeland Security (DHS),
and the Environmental Protection Agency (EPA)--have provided oversight
to CSB. EPA's IG currently provides oversight. Together, over time,
these IGs have made 32 recommendations to address problems in
management accountability and control, human capital management,
compliance with its statutory requirements, and other issues.
In response to a mandate in the Joint Explanatory Statement that
accompanied the fiscal year 2008 Consolidated Appropriations Act,
[Footnote 4] we examined (1) how CSB has responded to GAO and IG
recommendations regarding CSB's investigative gap, data quality
problems, human capital problems, and accountability and management
problems for meeting its mission requirements and (2) the merits of the
current oversight approach using an existing office of inspector
general and other alternative approaches to oversight. On April 17,
2008, we briefed staff from the House and Senate Appropriation
Subcommittees on Interior, Environment, and Related Agencies and on May
20, 2008, we briefed the Chairman of the House subcommittee. This
letter summarizes the main points from our presentation. See enclosure
II for a copy of the briefing slides from that presentation.
To perform our review, we reviewed relevant documentation and data and
interviewed CSB and other agency officials. We conducted this
performance audit from October 2007 to May 2008 in accordance with
generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives. We determined that the agency's accident-
screening database is sufficiently reliable for the purpose of making
broad estimates of the total number of accidents and accidents with
fatalities. Among the data's limitations is the lack of quality
controls to ensure that data are accurate and complete, especially with
respect to fatalities. For additional information on our scope and
methodology, see enclosure I.
Summary of Findings:
* CSB has implemented some GAO and IG recommendations related to
improving its operating policies and procedures since we last reported
in July 2000. However, we found that CSB has not fully addressed
several critical recommendations, and problems in governance,
management, and oversight persist. Specifically, CSB has not fully
responded to key recommendations related to investigating more
accidents that meet statutory requirements triggering CSB's
responsibility to investigate, improving the quality of its accident
data, resolving human capital problems, and ensuring accountability and
continuity of management.
* In our view, independent oversight from an existing IG remains the
most effective way to help CSB address its continuing problems,
provided that the arrangement is made permanent and funding is provided
to the IG for the function.
We are making recommendations to the Chairman of CSB to address
continuing problems with governance and management. We are also
proposing matters for congressional consideration to address continuing
problems with oversight. Regarding the six recommendations, CSB
generally concurred with four and disagreed with two. CSB also
disagreed with both matters for congressional consideration. CSB did
not generally concur with our recommendation to develop a plan to
address the investigative gap and request the necessary resources from
Congress to meet its statutory mandate but stated that it would work
with Congress to clarify the issue of its statutory mandate and, if
appropriate, seek an amendment to CSB's authorizing statute. We believe
that CSB's willingness to work with Congress to clarify the issue of
its statutory mandate, and if appropriate, seek an amendment to CSB's
authorizing statute is a step in the right direction. However, CSB does
not agree that it must currently investigate all chemical accidents
that meet statutory requirements triggering CSB's responsibility to
investigate. In this regard, CSB said it has "not construed the
agency's authorizing statute as requiring investigation of every
chemical accident involving a fatality, serious injury, or substantial
property damage, or the potential for such consequences." We continue
to believe the current law is clear; investigations are required for
all accidental releases that result, or have the potential to result,
in a fatality, serious injury, or substantial property damage. CSB is
currently investigating far fewer accidents than is required by law and
a plan to address the investigative gap is still necessary.
CSB also disagreed with our recommendation to publish a regulation to
require facilities to report information on chemical accidents. We are
encouraged that CSB plans to publish in the Federal Register a Request
for Information (RFI) concerning a reporting regulation to obtain the
views and opinions of CSB's stakeholders. We recognize that this step
could provide valuable information regarding the preparation of a
reporting regulation. However, the request for information does not in
itself provide assurance that CSB will follow through and issue a
regulation as required by CSB's authorizing statute. In this regard,
CSB said that "a reporting regulation is not needed for the narrow
purpose of notifying the CSB of major accidents warranting the
deployment of investigators, which appears to be the sole purpose of
CSB's authority to issue a reporting rule." We disagree with CSB's view
that a reporting regulation is not needed. CSB is legally required to
promulgate a regulation. Furthermore, such a regulation would allow CSB
to obtain more accurate, complete information to meet its statutory
mandate.
In addition, CSB disagreed with our matter for congressional
consideration to consider amending CSB's authorizing statute or the
Inspector General (IG) Act of 1978 to permanently give EPA's Inspector
General the authority to serve as the oversight body for the agency.
CSB questioned the independence of the EPA IG, since CSB issues
recommendations to EPA. We understand CSB's concerns; however, the IG
Act requires inspectors general to be independent from the agencies
they audit and investigate, and using the EPA IG does not pose a risk
to CSB's independent evaluation of chemical accidents.[Footnote 5]
Finally, CSB disagreed with our matter for congressional consideration
to provide the EPA IG with appropriations and staff allocations
specifically for the audit of CSB via a direct line in the EPA
appropriation. CSB said GAO did not adequately consider different
oversight options for CSB and that oversight should be tailored to the
size of the agency. We believe that all significant federal programs
and entities should be subject to oversight by IGs who can provide
sound independent audits of all significant federal operations and
activities. The EPA IG has expertise involving the chemical management
issues that the Board is charged with investigating, has gained
knowledge of CSB's operations and activities in providing the Board
with oversight over the past several years, and, like other IGs, has
the requisite independence provided by the IG Act of 1978 necessary for
reviewing and making recommendations to address long-standing problems
in the Board's management performance. Given the management problems
that our audit revealed, the need for independent IG oversight at CSB
is especially pressing.
CSB Has Not Fully Addressed Key Recommendations, and Problems Persist:
CSB has not fully responded to recommendations related to its
investigative gap, data quality, human capital, and management
problems, and we found these problems continue.
The Investigative Gap Persists:
CSB has not fully responded to recommendations to address its
investigative gap--the difference between the number of accidents it
investigates and the accidents that meet statutory criteria triggering
CSB's responsibility to investigate--and this gap persists. Using
fiscal year 2002 data, the DHS IG reported in fiscal year 2004 that CSB
deployed to 4 of 294 accidents that met statutory criteria for
investigation. Moreover, while acknowledging that CSB lacked the
resources to investigate all 294 accidents, the IG reported that CSB
did not have a plan for reporting to Congress on the number and type of
accidents it was not able to investigate, nor did it have a plan for
narrowing the investigative gap. Consequently, the IG recommended that
CSB develop a plan to describe and address the investigative gap and
include the information in future budget submissions to Congress and
the Office of Management and Budget (OMB). In response, CSB prepared a
onetime report to Congress in 2006. CSB officials told us they did not
repeat this report because congressional staff did not request
subsequent annual reports with this level of detail. Rather, it
included less detailed information in subsequent budget justifications
to Congress.
In fiscal year 2007, we found that CSB received notifications of 920
chemical accidents; approximately 35 of these accidents included at
least one fatality, and CSB investigated 1 of these. By not
investigating all accidental releases that have a fatality, serious
injury, substantial property damage, or the potential for a fatality,
serious injury, or substantial property damage, CSB continues to fall
short of its statutory mandate. CSB officials said the agency lacks the
resources to investigate more than a small percentage of the accidents
that meet statutory criteria triggering the board's responsibility to
investigate. Moreover, CSB has not developed a long-term plan for
reporting to Congress on the scope and magnitude of its investigative
gap or a detailed strategy to address it. As a result, Congress does
not have accurate or comprehensive information about CSB's
investigative gap or the resources it would need to close it.
When we compared CSB and NTSB data from 2006, we found that while
NTSB's budget is approximately 8 times CSB's budget, NTSB investigates
250 times as many accidents. Unlike CSB, NTSB conducts limited, office-
based investigations that rely on the work of other entities. NTSB uses
its statutory authority to solicit other entities' work when resources,
or other considerations, prevent it from deploying investigators to the
accident site, a fact that may help it better leverage its resources.
For example, NTSB uses the work of local officials, rescue response
units, Federal Aviation Administration (FAA) personnel, and other
persons and organizations that might have knowledge of the accident.
While CSB has similar statutory authority to use information gathered
by others, the agency terminated its limited, office-based review
program that relied on other entities work in 1999. Although the
limited review program was less resource intensive than full
investigations, CSB officials said that they terminated the limited
reviews because relying on the work of other agencies conflicted with
CSB's independence. In 2006, we reported that NTSB's use of others'
work may present some challenges, but appears to be working well.
[Footnote 6] Moreover, CSB has memorandums of understanding with both
Occupational Safety and Health Administration (OSHA) and EPA that state
that CSB may use information gathered by OSHA and EPA to aid in its
investigation of accidents.
Data Quality Problems Continue:
CSB has not fully responded to IG recommendations to publish a data-
reporting regulation and improve the quality of its accident data. As a
result, data quality problems continue. In 2004, the DHS IG recommended
that CSB fulfill its statutory requirement to publish a regulation for
receiving information from facilities on their chemical accidents, and
that CSB develop a long-term strategy to improve the quality of its
data. Since that time, CSB has not issued the regulation, and officials
said they have no plans to do so; instead CSB relies primarily on the
media, such as online newspapers and television, to learn about
chemical accidents. In addition, the DHS IG reported that CSB did not
have adequate controls over the quality of data in the accident-
screening database it uses to report to Congress and the public on the
number of chemical accidents the agency screens and selects for
investigation. The IG reported that CSB needed to monitor its data for
completeness, accuracy, timeliness, and usefulness.
We found that CSB lacks a long-term strategy to improve quality
controls, and the data remain somewhat inaccurate and incomplete. For
example, when we analyzed a subset of accidents in the database
involving fatalities and injuries, we found at least five accidents
(about 6 percent of the cases reviewed) where fatalities were not
correctly recorded in the database. We also found seven accidents
(about 4 percent of the cases reviewed) where data on injuries were
missing as a result of incomplete data entry. Moreover, CSB does not
have procedures to ensure that data has been entered accurately. The
lack of data-reporting regulations and these data quality problems
limit CSB's ability to target its resources, identify trends and
patterns in chemical accidents, and prevent future similar accidents.
Human Capital Problems Persist:
CSB has not fully responded to recommendations to resolve its human
capital problems. In 2002, the FEMA IG found that CSB had a shortfall
of investigators and had not made hiring them a priority. In addition,
it found that CSB lacked a central human capital manager, comprehensive
strategic human capital plan, and performance measures and criteria.
The FEMA IG recommended that CSB make hiring investigators a top
priority and made several recommendations to strengthen its human
capital planning and management.
In response, CSB consolidated human capital responsibilities under a
full-time human resources manager, developed several agencywide goals
to improve human capital, and hired more investigators; however, we
found that CSB's human capital strategy was not comprehensive, lacked a
detailed action plan for closing the investigator shortfall, did not
include input from staff investigators, and lacked performance
measures--actions included in the Strategic Management of Human Capital
portion of the President's Management Agenda.
CSB officials told us they have difficulties attracting and retaining
investigators. We found that more employees left CSB in fiscal years
2006 and 2007 than were hired. In fiscal years 2006 and 2007, three of
five investigators who left were senior investigators with 5 to 7 years
of experience. Yet CSB hired mostly interns during the same 2 fiscal
years. CSB hired these interns through the Federal Career Intern
program, which is designed to attract and retain employees for federal
service. However, some officials we interviewed, including a board
member, investigation managers, and investigators, told us intern
investigators are encouraged to leave CSB to gain experience in private
industry or to pursue graduate degrees. In addition, CSB officials said
they offered retention bonuses to high-performing mid-and senior-level
investigators before they left the agency. However, the investigators
declined the bonuses because these individuals said they received
significantly higher compensation from the private sector. In addition,
CSB officials said they did not offer retention bonuses to resigning
intern investigators because they did not think it would make a
difference since these individuals would be earning more in their new
jobs. We found that the agency has not paid a retention bonus to any
employee since September 2002. Moreover, we found that in fiscal year
2006, CSB reprogrammed compensation funds of $627,891 to other
priorities, including producing safety videos and redesigning its Web
site, and that in fiscal year 2007, CSB reprogrammed compensation funds
of $407,383 to similar purchases.
Accountability and Management Problems Continue:
CSB has not fully responded to recommendations to delegate the
authority to effectively manage the day-to-day administrative functions
to a permanent chief operating officer (COO). In March 2002, the FEMA
IG cited fractured management, a weakened chain of command, and board
member intervention in routine administration and recommended that the
board delegate day-to-day administrative functions to a permanent COO
to ensure continuity of management and accountability. In response to
the FEMA IG's recommendation, CSB hired a COO in 2002 to effectively
manage the day-to-day operations of CSB, but the individual left in
2004. The board subsequently eliminated the position and transferred
the COO's responsibilities to individual program managers and the
board.
We found that CSB lacks a permanent senior executive to establish
performance goals, hold program mangers accountable for meeting those
goals, and demonstrate improvement in the agency's ability to meet its
statutory mandate over time. Without a COO, the agency may be unable to
ensure continuity of performance and accountability when board members
and chairs leave the agency.
CSB board members said that a similar executive director position might
reduce the administrative responsibilities of the board; however, in
comments to GAO, CSB did not support filling a COO or similar position
at this time because a COO is not likely to provide any additional
management skills not already represented at the agency. The
investigation managers and investigators we interviewed generally
expressed support for reinstating the COO position to improve the
continuity of administrative management.
Inspector General Oversight Is Still Warranted:
On the basis of our review of CSB's history and current operations; we
believe that the independent institutional audit presence of an IG
remains the best option for ensuring that CSB is accountable to
Congress for meeting its statutory requirements. We reconsidered the
three options for oversight we suggested in 2000, which include (1)
establishing an in-house audit and investigations unit, (2) contracting
out for evaluations of its operations and programs, and (3) obtaining
the services of an existing office of inspector general. We determined
that the first two options are not appropriate for the board for
several reasons. The first option--an in-house audit unit--is not
practical because CSB's history of management problems warrants a level
of independent oversight that may be difficult to achieve by an
internal audit function. In addition, the limited staffing that would
reasonably be allocated to this function at an agency of this size
would lack the varied expertise needed to address these problems. The
second option--contracting out for evaluations--is not appropriate
because of the limitations of contracting in terms of both audit
independence and the potentially limited duration of the contracting
relationship. CSB officials told us they prefer the second option
because they believe CSB's small size does not justify independent
institutional IG oversight. In addition, CSB officials said that CSB is
classified as one of 54 federal entities defined in the IG Act of 1978
for which the act did not provide an IG, but rather required annual
reporting of their audit and investigative activities to Congress and
the Office of Management and Budget. However, in our view, the CSB's
long-standing, serious, and intractable management problems make it
unlikely that the reporting requirements for federal entities will
ensure that the CSB has an appropriate level of oversight to address
its management problems.
Given these factors, in our view IG oversight remains the most
appropriate oversight option for CSB. Nonetheless, we recognize that
there are some shortcomings with the current EPA IG's oversight
relationship. First, the arrangement is not permanent, a fact that may
undermine the continuity of oversight. Second, EPA IG officials told us
they have no plans to conduct future program evaluations of CSB because
they are allocating their limited evaluation resources to other
priority issues within EPA. However, we do not believe, as CSB asserts,
that the EPA IG's assignment and work call into question CSB's intended
independence from EPA. According to CSB, CSB independently evaluates
and reports to Congress on EPA programs in chemical accident
prevention, and CSB's independence from EPA was deliberate and
carefully considered. By statute, inspectors general are independent
from the agencies they audit and investigate so the EPA IG must
maintain his or her independence from EPA officials and program
employees. With such independence, the IG poses no risk to CSB's
independent evaluations of chemical accidents.
Conclusions:
After 10 years of operation, CSB continues to operate in noncompliance
with its statutory mandates. CSB stresses that it recognizes the
importance of its investigations to identify root causes of accidental
releases and recommend regulatory action to prevent such accidental
releases, but it is not investigating all chemical releases that have a
fatality, serious injury, substantial property damage, or the potential
for a fatality, serious injury, or substantial property damage.
Given the resource constraints on the board that limit its ability to
investigate all chemical accidents resulting in fatalities, serious
injuries, or substantial property damage, it is particularly important
that CSB better leverage its existing resources by using other
entities' work, have the best available data on which to make decisions
on those accidents that are most important to investigate, and use all
available human capital tools to retain staff. Even though CSB has a
statutory requirement to issue a regulation requiring facilities to
report their chemical releases, the board has resisted requiring such
reporting, preferring to rely on alternative information sources, such
as major news organizations. Requiring facilities to report certain
information on accidental releases would provide CSB with better data
than it currently receives from media sources.
The difficulties that CSB has experienced are largely the result of
inadequate management accountability for addressing long-standing
problems and for clearly identifying and attempting to meet CSB's staff
requirements to perform investigations of chemical accidents. While we
recognize that CSB may not have sufficient resources to investigate
every accident within its purview, as NTSB reports it does, we believe
CSB is missing opportunities to investigate more accidents and possibly
prevent fatalities, serious injuries, and substantial property damage
in the future. For example, other federal agencies, such as EPA and
OSHA, collect accident information that, to the extent that the
information meets CSB's data quality standards, could provide
additional resources to help the board meet its mission.
Recommendations for Executive Action:
We recommend that the chairman of the Chemical Safety Board:
* develop a plan to address the investigative gap and request the
necessary resources from Congress to meet CSB's statutory mandate or
seek an amendment to its statutory mandate;
* consider using the work of other entities, such as government
agencies, companies, and contractors (subject to an assessment of the
quality of their work), to a greater extent to maximize the board's
limited resources;
* improve the quality of its accident-screening database by better
controlling data entry and periodically sampling accident data to
evaluate their consistency and completeness;
* publish a regulation requiring facilities to report all chemical
accidents, as required by law, to better inform the agency of important
details about accidents that it may not receive from current sources;
* consider reinstating the position of chief operating officer, with
delegations of responsibility for establishing performance goals,
holding program mangers accountable for meeting those goals, and
demonstrating improvement in the agency's ability to meet it statutory
mandates over time; and:
* use the Strategic Management of Human Capital portion of the
President's Management Agenda to provide criteria for developing a
comprehensive human capital plan, with input from investigators that
includes specific objectives and performance measures to improve
accountability for results and to assist the agency in its goal of
improving its human capital and infrastructure.
Matters for Congressional Consideration:
Congress may wish to consider amending CSB's authorizing statute or the
Inspector General Act of 1978 to permanently give EPA's Inspector
General the authority to serve as the oversight body for the agency.
As Congress prepares the appropriation of the EPA Inspector General, it
may wish to consider providing the Inspector General with
appropriations and staff allocations specifically for the audit
function of CSB via a direct line in the EPA appropriation.
Agency Comments and Our Evaluation:
We provided a draft of our report to CSB for its review and comment. We
received written comments from CSB's Chairman and Chief Executive
Officer (CEO). These comments and our detailed response to them are
presented in enclosure III. CSB also provided technical comments, which
we have incorporated into the report as appropriate.
Regarding the six specific recommendations we made in the report, CSB
generally concurred with four and disagreed with two. CSB also
disagreed with both matters for congressional consideration we
identified in the report. CSB generally concurred that it should (1)
consider using the work of other entities to maximize the board's
limited resources, (2) improve the quality of its accident-screening
database, (3) consider reinstating the position of chief operating
officer, (4) use the Strategic Management of Human Capital portion of
the President's Management Agenda as a guide for developing a
comprehensive human capital plan.
CSB did not generally concur with our recommendation to develop a plan
to address the investigative gap and request the necessary resources
from Congress to meet its statutory mandate. The agency reports that it
will seek additional investigation resources and "will draft a plan for
obtaining information on additional chemical accidents occurring in the
United States, and clearly set forth a risk-based approach to accident
selection and investigation." However, it does not commit to meet CSB's
statutory mandate for investigating chemical releases, citing its view
that "CSB has not construed the agency's authorizing statute as
requiring investigation of every chemical accident involving a
fatality, serious injury, or substantial property damage, or the
potential for such consequences." CSB has not explained the basis for
its interpretation. The 1990 Clean Air Act Amendments establishing the
CSB states "[t]he Board shall investigate (or cause to be
investigated)�any accidental release resulting in a fatality, serious
injury or substantial property damage." Further, the act states that
"in no event shall the Board forgo an investigation where an accidental
release causes a fatality or serious injury among the general public,
or had [sic] the potential to cause substantial property damage or a
number of deaths or injuries among the general public." As noted in our
briefing, this language clearly identifies which accidental releases
CSB is required to investigate; that is, investigations are required
for all accidental releases that result, or have the potential to
result, in a fatality, serious injury, or substantial property damage.
Although CSB did not agree with this interpretation, the agency stated
that it would work with Congress to clarify the issue of its statutory
mandate and, if appropriate, seek an amendment to CSB's authorizing
statute. We believe that CSB's willingness to work with Congress to
clarify its statutory mandate is a step in the right direction.
However, we continue to believe the current law is clear; CSB should
meet its current mandate or seek an amendment to its authorizing
statute.
CSB disagreed with our matter for congressional consideration to
consider amending CSB's authorizing statute or the IG Act of 1978 to
permanently give EPA's Inspector General the authority to serve as the
oversight body for the agency. CSB said that while the EPA IG is one
option for oversight, other offices of inspector general are also
available, some of which may be more appropriate for the role. CSB also
questioned the independence of the EPA IG, since CSB issues
recommendations to EPA program offices. We assessed other options for
oversight that we had considered in our 2000 report, as well as options
presented to us by CSB. We understand CSB's concerns; however, the IG
Act requires inspectors general to be independent from the agencies
they audit and investigate. The EPA IG has expertise involving the
chemical management issues that the Board is charged with
investigating, has gained knowledge of CSB's operations and activities
in providing the Board with oversight over the past several years, and,
like other IGs, has the requisite independence provided by the IG Act
of 1978 necessary for reviewing and making recommendations to address
long-standing problems in the Board's management performance. As a
result, using the EPA IG does not pose a risk to CSB's independent
evaluation of chemical accidents.
CSB also disagreed with our matter for congressional consideration to
provide the EPA IG with appropriations and staff allocations
specifically for the audit of CSB via a direct line in the EPA
appropriation. CSB said GAO did not adequately consider different
oversight options for CSB and that oversight should be tailored to the
size of the agency. CSB also noted that it currently obtains its
financial and information security audits for about $60,000 a year. We
believe that all significant federal programs and entities should be
subject to oversight by IGs who can provide sound independent audits of
all significant federal operations and activities. Given the management
problems that our audit revealed, the need for independent IG oversight
at CSB is especially pressing. Further, financial and information
security audits are not a substitute for the oversight of program
management provided by an independent IG.
We are sending copies of this report to the Chairman and CEO of the
Chemical Safety and Hazard Investigation Board, appropriate
congressional committees, and other interested parties. We will also
make copies available to others upon request. In addition, the report
will be available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at 202-512-3841 or [email protected]. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Major contributors to this report were
Ed Kratzer, Assistant Director; Vanessa Dillard; Brian M. Friedman;
Angela Miles; Alison O'Neill; Michael Sagalow; Rebecca Shea; John C.
Smith; and Jeanette Soares.
Signed by:
John B. Stephenson:
Director, Natural Resources and Environment:
Enclosures:
Congressional Addressees:
The Honorable Dianne Feinstein:
Chairman:
The Honorable Wayne Allard:
Ranking Member:
Subcommittee on Interior, Environment, and Related Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Norman D. Dicks:
Chairman:
The Honorable Todd Tiahrt:
Ranking Member:
Subcommittee on Interior, Environment, and Related Agencies:
Committee on Appropriations:
House of Representatives:
[End of section]
Enclosure I: Scope and Methodology:
To perform our review, we analyzed authorizing statutes, regulations,
legislative history, and GAO and office of inspector general (IG)
reports, and other literature. We also reviewed and analyzed the
Chemical Safety and Hazard Investigation Board's (CSB) strategic plan,
human capital report, policies and procedures, and other program
documents, and compared them to similar documents from the National
Transportation Safety Board (NTSB). In addition, we reviewed a subset
of CSB's accident screening database that included two variables CSB
uses to rank the seriousness of an accident--fatalities and injuries
and the narratives explaining these accidents. We also consulted GAO's
guidance on management best practices, human capital, data reliability,
and oversight. In addition, we interviewed officials from CSB,
officials from past and current IGs. We also consulted NTSB officials
and GAO experts on management, data reliability, human capital, and
oversight issues.
We did not evaluate the quality of CSB's investigative products issued
to date, or the quality and effectiveness of its reports,
recommendations, and promotion of preventive actions, because these
evaluations were outside the scope of our mandate and are not relevant
to the findings and conclusions of this engagement. We also did not
conduct a detailed evaluation of the oversight arrangements for the
other 53 federal entities for comparison with CSB because the
continuing management problems found in our audit highlight the need
for IG oversight.
We conducted this performance audit from October 2007 to May 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. We determined that the
agency's accident screening database is sufficiently reliable for the
purpose of making broad estimates of the total number of accidents and
accidents with fatalities. Among the data's limitations is the lack of
quality controls to ensure that data are accurate and complete,
especially with respect to fatalities.
[End of section]
Enclosure II: Slides from April 17, 2008, Briefing to Congressional
Staff:
Chemical Safety Board: Improvements in Management and Oversight Are
Needed:
Briefing to the Subcommittees on Interior, Environment, and Related
Agencies:
Committee on Appropriations:
U.S. Senate:
U.S. House of Representatives:
Background:
The Chemical Safety and Hazard Investigation Board (CSB) is an
independent agency that was created under the Clean Air Act Amendments
of 1990 and began operating in 1998. The act directed CSB to:
* investigate and report on the cause or probable cause of any
accidental chemical releases resulting in a fatality, a serious injury,
or substantial property damage;
* make recommendations to reduce the likelihood or consequences of
accidental chemical releases and propose corrective measures; and;
* establish regulations for reporting accidental releases.
Congress modeled CSB after the National Transportation Safety Board
(NTSB), which has a similar mission.
Like NTSB, CSB has no enforcement authority and a limited regulatory
role.
As outlined in the statute, CSB is to be managed by a five-member
board. Currently the board has one vacancy.
In fiscal year 2009, CSB requested $10.6 million and 47 staff.
In fiscal year 2000, CSB requested $12.5 million and 60 staff.
Prior year appropriations and on-board staff levels include:
* fiscal year 2008, $9.4 million and 39 staff (as of 1/30/2008);
* fiscal year 2006, $9.2 million and 41 staff (as of 9/30/2006);
* fiscal year 2004, $8.2 million and 40 staff (as of 9/30/2004); and;
* fiscal year 2000, $8.0 million and 27 staff (as of 6/15/2000).
In 2000, GAO reported problems with CSB�s governance, management,
policies, and procedures and recommended, among other things, that CSB
obtain the services of an existing office of inspector general (IG).
Since fiscal year 2001, three existing IGs have provided oversight to
CSB: Federal Emergency Management Agency (FEMA), the Department of
Homeland Security (DHS), and the U.S. Environmental Protection Agency
(EPA). EPA�s IG currently provides oversight.
From fiscal year 2002 through 2007, inspectors general have made 32
recommendations to address problems in management accountability and
control, human capital management, compliance with its statutory
requirements, and other issues.
[End of section]
Objectives:
You asked us to examine:
1. how CSB has responded to GAO and IG recommendations regarding CSB�s
investigative gap, data quality problems, human capital problems, and
accountability and management problems for meeting its mission
requirements and;
2. the merits of the current oversight approach�using an existing
office of inspector general�and other alternative approaches to
oversight.
Scope and Methodology:
To answer these questions, we reviewed:
* authorizing statutes, regulations, legislative history and GAO and IG
reports, and other literature;
* CSB�s accident screening database for fiscal year 2006 and fiscal
year 2007;
* CSB�s strategic plan, human capital report, and other program
documentation such as policies and procedures;
* similar program documents from NTSB for comparison to CSB documents;
* GAO guidance pertaining to management best practices, human capital,
data reliability, and oversight; and;
* The mission and oversight arrangements for 54 federal entities,
including CSB, as defined by the Inspector General Act of 1978.
We did not review or evaluate the quality or effectiveness CSB�s
products, recommendations or preventive actions as that was outside the
scope of our mandate and not relevant to this engagement�s findings and
conclusions.
We also interviewed officials from CSB and past and current IGs and
consulted GAO experts on management, data reliability, human capital,
and oversight issues.
We conducted this performance audit from October 2007 to May 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. We determined that the
agency�s accident-screening database is sufficiently reliable for the
purpose of making broad estimates of the total number of accidents and
accidents with fatalities. Among the data�s limitations is the lack of
quality controls to ensure that data are accurate and complete,
especially with respect to fatalities.
[End of section]
Results in Brief:
CSB has implemented some GAO and IG recommendations related to
improving its operating policies and procedures since we last reported
in July 2000. However,CSB has not fully addressed several critical
recommendations, and problems in governance, management, and oversight
persist. Specifically, CSB has not fully responded to key
recommendations related to (1) investigating more accidents that meet
statutory requirements triggering the CSB�s responsibility to
investigate,(2) improving the quality of its accident data, (3)
resolving human capital problems, and (4) ensuring accountability and
continuity of management.
In our view, independent oversight from an existing IG remains the most
effective way to help CSB address its continuing problems, provided
that the arrangement is made permanent and funding is provided to the
IG for the function. CSB officials disagreed based on the agency�s
small size and its existing annual reporting requirements to Congress
and the Office of Management and Budget.
Therefore:
* We are making recommendations to the Chair of CSB to address
continuing problems with governance and management.
* We are proposing matters for congressional consideration to address
continuing problems with oversight.
[End of section]
The investigative gap persists:
CSB has not fully responded to recommendations to address its
investigative gap�the difference between the number of accidents it
investigates and the accidents that meet statutory criteria triggering
CSB�s responsibility to investigate.
Initial problem: Using fiscal year 2002 data, the DHS IG reported in
fiscal year 2004 that of the 613 accidents CSB screened, about 294 met
statutory criteria, and CSB deployed investigators to 4. Moreover,
while acknowledging that CSB lacked the resources to investigate all
294 accidents, the IG reported that CSB did not have a plan for
reporting to Congress on the number and type of accidents it was not
able to investigate or a plan for narrowing the investigative gap.
IG�s recommendation: The DHS IG recommended that CSB develop a plan to
describe and address the investigative gap and include the information
in future budget submissions to Congress and OMB.
How CSB responded: Two years after the IG made the recommendation, CSB
prepared a onetime report to Congress in 2006. The report described 14
accidents occurring in 1 year that it said it would have investigated
if it had had the resources. However, the report did not describe a
plan to address the investigative gap identified by DHS IG.
* CSB has not repeated this report; rather, it included less detailed
information in subsequent budget justifications to Congress.
* CSB officials told us that congressional staff did not request
subsequent annual reports with this level of detail.
* CSB officials also said the agency lacks the resources to investigate
more than a small percentage of the accidents that meet statutory
criteria triggering the board�s responsibility to investigate.
Problem remaining: CSB continues to underestimate the number of
accidents it would need to investigate to meet statutory requirements.
In addition, it has not significantly narrowed its investigative
gap�investigating about 6 accidents each year from fiscal years 2004
through 2007. Moreover, CSB has not developed a long-term plan for
reporting to Congress on the scope and magnitude of its investigative
gap or a detailed strategy to address it. Therefore:
* CSB continues to fall short of its statutory mandate, and accidents
that involve fatalities, serious injuries, and substantial property
damage go uninvestigated.
* Congress does not have accurate or comprehensive information about
CSB�s investigative gap or the resources it would need to close it.
In fiscal year 2007, CSB investigated less than 1 percent (5 of 920) of
accidents of which it was notified.
Examples of accidents in fiscal years 2006 and 2007 that CSB did not
investigate include:
* An oil well explosion that killed 3 teens.
* A methanol flash fire at a school that injured 8 students and their
teacher. Three students and the teacher were hospitalized for burns on
their upper torsos, faces, and hands.
* A natural gas well explosion that killed 1 worker and forced hundreds
of residents out of their homes for hours.
* A propane explosion that killed 3 workers and injured 47.
* A waste-processing plant that released noxious chemicals and may have
sickened more than 200 people.
Table 1: Information on Chemical Accidents and Investigations, Fiscal
Years 2006 and 2007:
Total accidents CSB recorded in its screened database:
2006: 822[A];
2007: 920[A].
Accidents CSB deployed to:
2006: 9[B];
2007: 8[B].
Accidents CSB investigated:
2006: 6;
2007: 5.
Accidents with fatalities:
2006: 38[A];
2007: 35[A].
Accidents with fatalities that CSB investigated:
2006: 5;
2007: 1.
Source: GAO analysis of CSB data.
[A] Because of data quality limitations, this total number of accidents
and accidents with fatalities identified and reported in the database
may be underestimated.
[B] The number of deployments is greater than the number of accident
investigations because CSB deployed to accidents it did not ultimately
investigate.
[End of table]
CSB and NTSB are both required to investigate all accidents meeting
certain criteria. NTSB is required to investigate (1) all civil
aviation accidents; (2) all pipeline accidents in which there is a
fatality, substantial property damage, or significant injury to the
environment; (3) all railroad accidents in which there is a fatality or
substantial property damage, or that involves a passenger train; and
(4) certain major marine casualties. Likewise, CSB is required to
investigate all accidental chemical releases into the air from
stationary sources that cause a fatality, serious injury, or
substantial property damage. NTSB does have discretion in selecting
which highway and "other modes of transportation" accidents to
investigate. CSB's authorizing statute does not give it any discretion
in selecting which accidents to investigate.
While NTSB�s budget is approximately 8 times CSB�s budget, NTSB
investigates 250 times as many accidents.
Figure 1 describes the annual budget and the number of investigations
CSB and NTSB started in fiscal year 2006.
Figure 1. CSB and NTSB Number of Accident Investigations Initiated and
Budget, fiscal year 2006:
[See PDF for image]
This figure is a vertical bar graph depicting the following data:
Investigations:
CSB: 6;
NTSB: 1,521.
Budget:
CSB: $9.1 million;
NTSB: $75.9 million.
Source: GAO analysis of CSB and NTSB data.
Note: The total of 1,521 is aviation accident investigations only.
Nonaviation accident investigations were excluded because the data were
not available in the source. NTSB's Performance and Accountability
Report. Nonaviation accident investigations include highway, marine and
rail, pipeline, and hazardous materials accident investigations. In
fiscal year 2006, NTSB completed 19 nonaviation accident
investigations.
[End of figure]
Both CSB�s and NTSB�s statutes allow the use of investigations
performed by other agencies. Unlike CSB, NTSB uses its authority to
solicit investigative work performed by others when resources or other
considerations prevent it from deploying to accident sites. In all
cases, overall investigative control, including determination of
probable cause, rests with NTSB.
NTSB's size prevents it from being on-site for many aviation
investigations; therefore, the agency conducts limited investigations
in which NTSB investigators do not go to the scene of the accident to
gather information but rather correspond with local officials, rescue
response units, Federal Aviation Administration personnel, and other
persons and organizations that might have knowledge of the accident.
The different types of NTSB aviation investigations are described in
attachment 2.
Similar to NTSB, CSB has the authority to use information gathered by
local officials, rescue response units, Occupational Safety & Health
Administration (OSHA) and EPA personnel, and other persons and
organizations to prepare its reports and thereby expand its knowledge
base of chemical accidents while operating with limited resources.
CSB has memorandums of understanding with OSHA and EPA that indicate in
certain instances, CSB may decide not to send an investigation team to
the site of a chemical incident but may collect incident information
from EPA, OSHA, or other on-site agencies compiled in the course of
their own actions.
Like NTSB, CSB has the ability to issue accident briefs, in addition to
more detailed accident reports. See attachment 3 for a description of
the types of NTSB accident reports.
We reported in 2000 that CSB discontinued its limited, office-based
review program that used investigative reports prepared by other
organizations that respond to accidents. While the limited review
program was less resource intensive than full investigations, board
officials told us that they terminated this practice in 1999 because it
conflicted with the board�s independence by having the board rely on
the work of other agencies.
In contrast, NTSB does conduct limited, office-based investigations
that rely on the work of other entities. We reported in 2006 that while
NTSB�s use of others� work may present some challenges, it appears to
be working well. Performing data reliability assessments of important
information based on the work of others is a generally accepted means
used by federal and private audit organizations. CSB could likewise use
existing reports and studies rather than performing comprehensive
investigations of its own.
[End of section]
Data quality problems continue:
CSB has not fully responded to IG recommendations to improve the
quality of its accident data.
Initial problem: CSB maintains an accident-screening database to report
to Congress and the public on the number of chemical accidents it
identifies and selects for investigation. However, the Department of
Homeland Security (DHS) IG reported that CSB had inadequate control
over the quality of its data and needed to monitor for completeness,
accuracy, timeliness, and usefulness.
The IG�s recommendation: The DHS IG recommended that CSB fulfill its
statutory requirement to publish a regulation for receiving information
from facilities on their chemical accidents. The IG also recommended
that CSB develop a long-term strategy to address the shortfall in
national chemical accident database quality.
How CSB responded: CSB has not issued the regulation and has no plans
to do so. According to CSB officials, the current system of monitoring
media reports, searching the Web, and obtaining accident reports from
NTSB and other sources is sufficient.
Problem remaining: According to CSB officials, they have resolved the
IG�s concerns about data quality; however, we found that CSB still has
not published a data-reporting regulation and lacks a long-term
strategy to improve quality controls, and the data remain somewhat
inaccurate and incomplete. For example, when we analyzed a subset of
accidents in the database involving fatalities and injuries, we found
at least five accidents (about 6 percent) where fatalities were not
correctly recorded in the database. We also found seven accidents
(about 4 percent) where data on injuries were missing as a result of
incomplete data entry. Moreover, CSB does not have procedures to ensure
that data were entered accurately.
CSB officials maintain that publishing a regulation to obtain
information from facilities on their chemical accidents is not
necessary because the information the board already receives is
sufficient. Without a regulation, CSB relies primarily on the media,
such as online newspapers and television, to learn about chemical
accidents. It is likely that information reported by facilities would
be a better source than CSB�s current practice of relying mostly on the
media. Information provided in media sources may contain errors and not
include the kind of information CSB needs to make decisions about which
accidents to investigate or provide the agency with the kind of
information needed for trend analysis and prevention outreach.
In addition, the lack of quality controls of CSB�s accident database
has contributed to data problems that could limit CSB�s ability to
accurately report information on the investigative gap to Congress,
target its resources, identify trends and patterns in chemical
accidents, and prevent future similar accidents.
[End of section]
Human capital problems persist:
CSB has not fully responded to recommendations to resolve its human
capital problems.
Initial problem: In 2002, the FEMA IG identified weaknesses in CSB�s
human capital management, particularly that it had a shortfall of
investigators, had not made hiring investigators a top priority, and
that it lacked a central human capital manager, a comprehensive
strategic human capital plan, and performance measures and criteria.
IG�s recommendation: The FEMA IG recommended that CSB make hiring a top
priority and made several recommendations to strengthen its human
capital planning and management.
How CSB responded: CSB consolidated human capital responsibilities
under a full-time human resources manager, developed several agencywide
strategies that included goals to improve human capital, hired more
investigators, and established a remote office in Denver for one senior
investigation manager. However, CSB officials acknowledged difficulties
in attracting senior investigators to live in the District of Columbia
and in retaining intern investigators.
Problem remaining: CSB�s human capital strategy was not comprehensive,
lacked a detailed action plan for closing the investigator shortfall,
did not include input from staff investigators, and lacked performance
measures�actions included in the Strategic Management of Human Capital
portion of the President�s Management Agenda. Therefore:
* CSB�s shortfall in investigators and problems retaining staff
continue, limiting the number of accidents CSB could investigate
regardless of resources.
* According to a board member and some investigation managers and
investigators we interviewed, intern investigators are encouraged to
leave CSB in order to gain private industry experience or to pursue a
terminal graduate degree. Encouraging interns to leave federal service
for private industry experience does not follow the purpose of the
Federal Career Intern program, which is designed to attract and retain
employees for federal service.
More employees left CSB in fiscal years 2006 and 2007 than were hired,
indicating a possible problem with retention.
CSB officials acknowledge a problem with hiring and retention; however,
the agency has not given a retention bonus to an employee since 2002.
Figure 2: Number of CSB Hires and Separations Fiscal Years 2006-2007:
[See PDF for image]
This figure is a stacked vertical bar graph depicting the following
data:
Number of employees hired:
Noninvestigative staff: 7;
Investigators: 4.
Number of employees left:
Noninvestigative staff: 9;
Investigators: 5.
Source: CSB's budget and staffing plan documents.
[End of figure]
In fiscal years 2006 and 2007, 3 of 5 investigators who left CSB were
senior investigators with 5-7 years of experience. Yet CSB hired mostly
interns during the same 2 fiscal years.
In fiscal years 2006 and 2007, 4 of 11 staff hired were investigators.
Three of the 4 investigators CSB hired were interns. CSB officials told
us that they can hire interns more easily than senior investigators.
Figure 3: CSB Investigators and Other Staff Hired, Fiscal Years
2006�2007:
[See PDF for image]
This figure is a pie-chart depicting the following data:
Investigators hired:
Senior Investigator, GS-13: 1;
Intern Investigators, GS-7: 3.
Other staff: 7.
Source: CSB's budget and staffing plan documents.
[End of figure]
According to CSB officials, an intern does not replace an experienced
senior investigator; after converting to a permanent position from the
intern position, it takes 3 to 5 years to become fully qualified.
However, CSB officials said retaining interns is a challenge and noted
that two of four intern investigators hired in fiscal years 2004 and
2005 left CSB and one transferred to another office.
If CSB had retained intern investigators hired in fiscal years 2004 and
2005, it would have two additional investigators with 3 years of
experience in fiscal year 2008.
CSB has not fully used strategies available to federal agencies that
are designed to recruit or retain staff, such as:
* Federal Career Intern Program�The purpose of the federal intern
program is to convert successful interns to permanent employees. The
majority of interns have left CSB.
* Education and training assistance�Intern investigators interested in
pursuing a graduate degree might remain at CSB if the agency offered
support for tuition and additional training.
* Retention bonuses�Federal agencies may pay a retention incentive to a
current employee if the agency determines that it is essential to
retain the employee. CSB has not given any employee a retention bonus
since September 2002.
* Remote offices�CSB has not expanded the use of remote offices.
In fiscal year 2006, CSB reprogrammed compensation funds of $627,891 to
other priorities, such as safety videos and redesigning a Web site. In
fiscal year 2007, CSB reprogrammed compensation funds of $407,383 to
similar purchases.
Had CSB made resolving human capital problems a top priority, these
funds could have been used during the year for recruitment and
retention bonuses, education and training assistance, and student loan
repayment to hire and retain investigators.
[End of section]
Accountability and management problems continue:
CSB has not delegated the authority to effectively manage the day-to-
day administrative functions to a permanent chief operating officer
(COO) to ensure continuity of management and accountability.
Initial problem: Between fiscal years 2000 and 2002, CSB did not have a
permanent COO or a fully staffed board with a chair. Uncertainties
surrounding the acting COO�s role and authority resulted in fractured
management, a weakened chain of command, and board member intervention
in routine administration.
IG�s recommendation: The IG recommended that the board delegate to the
COO the authority to effectively manage the day-to-day operations of
CSB.
How CSB responded: CSB hired a COO in June 2002, but the individual
left after 2 years. The board subsequently eliminated the position and
transferred the COO�s responsibilities to individual program managers
and the board.
* CSB board members said that a COO or similar executive director
position might reduce the administrative responsibilities of the board,
however, the CSB Chairman said a COO is unlikely to provide any
additional management skills not already represented at the agency. Two
investigation managers and two investigators we interviewed generally
expressed support for reinstating the COO position to improve the
continuity of administrative management.
* EPA IG officials told us that there was support for the COO position
among the CSB employees (former and current) they interviewed during
their investigation in fiscal year 2007. These CSB employees indicated
that they preferred how things operated when the COO was present.
Problem remaining: CSB continues to operate without a permanent COO or
a fully staffed board. Therefore:
* CSB lacks a permanent senior executive with responsibility to
establish performance goals, hold program managers accountable for
meeting those goals, ensure there is a shared vision among board
members and managers,and demonstrate improvement in the agency�s
ability to meet it statutory mission over time.
* CSB may not be able to ensure continuity of performance and
accountability when board members and chairs leave the agency.
* Regardless of the board�s staffing status, GAO has recommended in the
past that employing a COO would provide long-term attention and focus
on management issues.
[End of section]
IG oversight is still warranted:
CSB�s history suggests that an IG�s continued independent institutional
audit presence is the best option for ensuring that CSB is more
accountable to Congress for meeting its public safety mission and
statutory requirements.As we reported in 2000, three options for
oversight include:
1. establishing an in-house audit and investigations unit,
2. contracting out for evaluations of its operations and programs, and,
3. obtaining the services of an existing office of inspector general.
We do not believe options 1 and 2 are appropriate for the board for
several reasons.
Option 1, an in-house audit unit, does not appear to be practical
because CSB�s history of management problems warrants a level of
independent oversight that may be difficult to achieve by an internal
audit function. In addition, the limited staffing that would reasonably
be allocated to this function at an agency of this size would lack the
varied expertise need to address these problems.
Option 2, contracting out for evaluations, also does not appear to be
appropriate because of the limitations of contracting in terms of both
audit independence and the potentially limited duration of the
contracting relationship�which would not provide the continuity of
oversight needed to address CSB�s long-standing management problems.
CSB officials told us they prefer option 2 because IG oversight is
inappropriate for an agency of CSB�s small size. CSB officials told us
that CSB is currently classified as 1 of 54 federal entities,as defined
by the IG Act of 1978, for which the act did not provide an IG.
* Under the IG Act, federal entities are required to report annually to
Congress and the Office of Management and Budget on whether an IG has
been established or what other actions the federal entity took to
otherwise ensure that audits of its programs and operations were
conducted.
CSB officials also told us that the IG Act provides a reasonable and
responsible level of oversight for federal entities and requested that
CSB be treated similarly to these entities. However, in our view, CSB�s
long-standing, serious, and intractable management problems make it
unlikely that this reporting requirement alone will ensure that the CSB
has an appropriate level of oversight necessary to address its
management problems.
Given CSB�s management problems, the fact that other federal entities
lack an IG should not determine whether CSB should have an IG. In any
event, by statute some other federal entities do have another agency�s
IG assigned to provide them with oversight. For example, the IG of the
Department of Agriculture is assigned to provide oversight to the Delta
Regional Authority. (Att. 1 provides the list of 54 federal entities,
as defined by the IG Act of 1978, and identifies 4 that have a critical
safety mission.)
Option 3, obtaining the services of an existing IG office, appears to
be the most appropriate oversight arrangement given the
serious,intractable management problems at CSB.
We believe that all significant federal programs and entities should be
subject to oversight by IGs who can provide sound independent audits of
all significant federal operations and activities. Given the management
problems that our audit revealed, the need for independent IG oversight
is especially pressing.
While we believe that IG oversight remains the most appropriate
oversight option, we found some shortcomings with the current EPA IG�s
oversight relationship:
* The current IG arrangement is not permanent, a fact that may
undermine the continuity of oversight; the EPA IG is assigned to serve
as CSB�s IG in annual appropriation bills.
* EPA IG officials told us they have no plans to conduct program
evaluations of CSB in fiscal year 2008 because they are allocating
their limited evaluation resources to other priorities within EPA.
However, we do not believe, as CSB asserts, that the EPA IG�s
assignment and work call into question CSB�s intended independence from
EPA. According to CSB, CSB independently evaluates and reports to
Congress on EPA programs in chemical accident prevention and CSB�s
independence from EPA was deliberate and carefully considered. By
statute, inspectors general are independent from the agencies they
audit and investigate so the EPA IG must maintain his or her
independence from EPA officials and program employees. With such
independence, the IG poses no risk to CSB�s independent evaluations of
chemical accidents.
[End of section]
Conclusions:
After 10 years of operation, CSB continues to operate in noncompliance
with its statutory mandates.
CSB stresses that it recognizes the importance of its investigations to
identify root causes of accidental releases and recommend regulatory
action to prevent such accidental releases but is not investigating all
chemical accidents that have a fatality, serious injury, property
damage, or the potential for a fatality, serious injury, or property
damage.
While we recognize that CSB may not have sufficient resources to
investigate every accident within its purview, as NTSB reports it does,
we believe CSB is missing opportunities to investigate more accidents
and possibly prevent fatalities, serious injures, and substantial
property damage in the future by not using the work of other entities.
In addition, given the resource constraints on the board that limit its
ability to investigate all chemical accidents resulting in fatalities,
serious injuries, or substantial property damage, it is particularly
important that CSB have the best available data on which to make
decisions on those accidents that are most important to investigate.
Even though CSB has a statutory requirement to issue a regulation
requiring facilities to report their chemical releases, the board has
resisted requiring such reporting, preferring to rely on alternative
information sources, such as major news organizations.
The difficulties that CSB has experienced in meeting its mission are
largely the result of inadequate management accountability for
addressing long-standing problems and for clearly identifying and
attempting to meet CSB�s staff requirements to perform investigations
of chemical accidents. In this regard, CSB has functioned without a
permanent chief operations officer with responsibility for holding
CSB�s managers accountable for their management activities and has not
developed a comprehensive human capital strategy to improve its efforts
to investigate chemical accidents in line with the board�s statutory
responsibilities.
[End of section]
Recommendations to the Agency:
We recommend that the chairman of the Chemical Safety Board:
* develop a plan to address the investigative gap and request the
necessary resources from Congress to meet CSB�s statutory mandate or
seek an amendment to its statutory mandate;
* consider using the work of other entities, such as government
agencies, companies, and contractors (subject to an assessment of the
quality of their work) to a greater extent to maximize the board�s
limited resources; and;
* improve the quality of its accident-screening database by better
controlling data entry and periodically sampling accident data to
evaluate their consistency and completeness.
* Publish a regulation requiring facilities to report all chemical
accidents, as required by law, to better inform the agency of important
details about accidents that it may not receive from current sources.
* Consider reinstating the position of chief operating officer, with
the delegation of responsibility for establishing performance goals,
holding program mangers accountable for meeting those goals, and
demonstrating improvement in the agency�s ability to meet its statutory
mandates over time.
* Use the Strategic Management of Human Capital portion of the
President�s Management Agenda to provide criteria for developing a
comprehensive human capital plan, with input from investigators, that
includes specific objectives and performance measures to improve
accountability for results and to assist the agency in its goal of
improving its human capital and infrastructure.
[End of section]
Matters for Congressional Consideration:
Congress may wish to consider amending CSB�s organic statute or the
Inspector General Act of 1978 to permanently give EPA�s Inspector
General the authority to serve as the oversight body for the agency.
As Congress prepares the appropriation of the EPA Inspector General, it
may wish to consider providing the Inspector General with
appropriations and staff allocations specifically for the audit
function of CSB via a direct line in the EPA appropriation.
[End of section]
Attachment 1: Federal entities, as defined by the IG Act of 1978:
1. Chemical Safety and Hazard Investigation Board*.
2. Defense Nuclear Facilities Safety Board[A].
3. National Transportation Safety Board[A].
4. Nuclear Waste Technical Review Board[A].
5. Advisory Council on Historic Preservation.
6. African Development Foundation.
7. American Battle Monuments Commission.
8. Architectural and Transportation Barriers Compliance Board.
9. Armed Forces Retirement Home.
10. Barry Goldwater Scholarship and Excellence in Education Foundation.
11. Christopher Columbus Fellowship Foundation.
12. Commission for the Preservation of America's Heritage Abroad.
13. Commission of Fine Arts.
14. Commission on Civil Rights.
15. Committee for Purchase from People Who Are Blind or Severely
Disabled.
16. Court of Appeals for Veterans Claims.
17. Court Services and Offender Supervision Agency for DC.
18. Delta Regional Authority.
19. Farm Credit System Insurance Corporation.
20. Federal Financial Institutions Examination Council.
21. Federal Mediation and Conciliation Service.
22. Federal Mine Safety and Health Review Commission.
23. Federal Retirement Thrift Investment Board.
24. Harry S. Truman Scholarship Foundation.
25. Inter-American Foundation.
26. Institute of American Indian and Alaska Native Culture and Arts
Development.
27. Institute of Museum and Library Services.
28. James Madison Memorial Fellowship Foundation.
29. Japan-U.S. Friendship Commission.
30. Marine Mammal Commission.
31. Merit Systems Protection Board.
32. Millennium Challenge Corporation.
33. Morris K. Udall Scholarship and Excellence in National
Environmental Policy Foundation.
34. National Capital Planning Commission.
35. National Commission on Libraries and Information Science.
36. National Council on Disability.
37. National Mediation Board.
38. Neighborhood Reinvestment Corporation.
39. Occupational Safety and Health Review Commission.
40. Office of Government Ethics.
41. Office of Navajo and Hopi Indian Relocation.
42. Office of Special Counsel.
43. Overseas Private Investment Corporation.
44. Presidio Trust.
45. Selective Service System.
46. Smithsonian Institution/John F. Kennedy Center for the Performing
Arts.
47. Smithsonian Institution/National Gallery of Art.
48. Smithsonian Institution/Woodrow Wilson International Center for
Scholars.
49. Trade and Development Agency.
50. U.S. Holocaust Memorial Museum.
51. U.S. Institute of Peace.
52. U.S. Interagency Council on Homelessness.
53. Vietnam Education Foundation.
54. White House Commission on the National Moment of Remembrance.
[A] Has a public safety mission.
[End of attachment]
Attachment 2: Types of NTSB Aviation Accident and Incident
Investigations:
Type of Investigations: Major investigation;
Number in Fiscal Year 2006: 7;
Description: Investigation of a significant accident that typically
involves fatalities, multiple injuries, considerable property damage,
or significant public interest. A team of investigators travels to the
accident site.
Travel involved? Yes.
Fatalities involved? Yes.
Type of Investigations: Field investigation[A];
Number in Fiscal Year 2006: 196;
Description: Investigation of an accident that typically involves a
fatality.At least one investigator travels and there is a significant
amount of follow-up investigation from the office.
Travel involved? Yes.
Fatalities involved? Typically yes.
Type of Investigations: Limited investigation[A];
Number in Fiscal Year 2006: 550;
Description: Investigation of accidents that can involve a fatality but
typically do not. Investigators do not travel to the accident site but
instead conduct a limited investigation using information collected by
Federal Aviation Administration officials, local officials, rescue
response units and other persons, and organizations that may have
knowledge of the incident.
Travel involved? No.
Fatalities involved? Typically no.
Type of Investigations: Data collection accident investigation;
Number in Fiscal Year 2006: 739.
Description: Investigations of accidents that do not involve any
fatalities, �critical� serious injuries, and other criteria.
Investigators do not travel to the accident site but instead collect
and analyze information from the office in order to determine the
cause.
Travel involved? No.
Fatalities involved? No.
Type of Investigations: Incident investigation[B];
Number in Fiscal Year 2006: 29;
Description: Investigation of occurrences that do not involve
fatalities. Investigators do not typically travel for these
investigations but instead conduct an investigation from the office.
Travel involved? No.
Fatalities involved? Typically no.
[A] Includes investigations of public use aircraft.
[B] These occurrences do not meet criteria to be defined as an official
accident but are still deemed important enough to investigate.
[End of table]
[End of attachment]
Attachment 3: Types of NTSB Accident Reports:
Type: Major accident reports;
Description: Reports that provide detailed narrative accounts of the
facts, conditions, circumstances, analysis, conclusions, and probable
cause of an accident. This type of report is issued for major aviation,
railroad, highway, pipeline, and marine accident investigations.
Type: Nonmajor accident reports (or �accident briefs�);
Description: Reports that briefly summarize the probable cause of an
accident. This type of report is issued for all aviation accidents and
for all nonmajor railroad, highway, pipeline, and marine accidents
investigated by or for NTSB, for which probable cause is determined.
[End of table]
[End of attachment]
[End of slide presentation]
Enclosure III: Comments from CSB:
Note: GAO comments supplementing those in the report text appear at the
end of this enclosure.
U.S. Chemical Safety and Hazard Investigation Board:
2175 K Street, NW, Suite 650:
Washington, DC 20037-1802:
Phone: (202) 261-7600:
Fax: 12021 261.7650:
[hyperlink, http://www.csb.gov]:
John S. Bresland, Chairman & CEO:
Gary L. Visscher, Board Member:
William B. Wark, Board Member:
William E. Wright, Board Member:
July 11, 2008:
John B. Stephenson:
Director:
Natural Resources and Environment:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Mr. Stephenson:
As requested, we reviewed your draft report, "Chemical Safety Board:
Improvements in Management and Oversight are Needed" that your office
provided on June 11, 2008. We agree on various points in the draft
report, such as the need to expand the investigation program. However,
as you are aware, the Chemical Safety and Hazard investigation Board
(CSB) has concerns with many of your conclusions and characterizations.
Rather than reiterate our concerns, we will focus our comments on your
recommendations. [See comment 1]
Before discussing individual recommendations, however, there is one
point that I particularly want to emphasize. The draft report refers to
previous Inspector General (IG) recommendations, and leaves the
impression, at least, that CSB has not been very responsive to those
recommendations. In fact all previous IG recommendations have been
closed by the respective IG's who made them. [See comment 2]
Investigative Gap:
GAO Recommendation: Develop a plan to address the investigative gap and
request the necessary resources from the Congress to meet the CSB 's
statutory mandate or seek an amendment to its statutory mandate.
CSB Response: The CSB has not construed the agency's authorizing
statute as requiring investigation of every chemical accident involving
a fatality, serious injury, or substantial property damage, or the
potential for such consequences, but understands GAO's concern and
recommendation. We also agree that the performance of our mission - to
help companies and communities avoid chemical accidents - would be
strengthened by investigating and reporting on more of the serious
chemical accidents that occur in the United States each year. [See
comment 3]
In addition to seeking additional investigation resources, we will
draft a plan for obtaining information on additional chemical accidents
occurring in the United States, and clearly set forth a risk-based
approach to accident selection and investigation. We will also work
with Congress to clarify the issue of CSB's statutory mandate, as
suggested by GAO, including if appropriate, an amendment to the CSB's
enabling legislation. [See comment 4]
We will examine the work of the National Transportation Safety Board
(NTSB) to aid our future plan. [See comment 5] However, we note that
the GAO's comparison between 6 CSB investigations and 1,521 NTSB
aviation investigations in FY 2006 may not be the most fruitful
benchmark for future planning. The majority of the NTSB's aviation
investigations were non-fatal general aviation incidents, with the NTSB
relying heavily on the work of 3,400 FAA regional inspectors to
determine the probable cause. Thus, the CSB will also examine the
NTSB's statutory authority and work in other modes of transportation.
In these other modes, the NTSB employs a risk based approach to select
out priority incidents from all incidents within its jurisdiction. [See
comment 6]
The purpose of increased resources, the plan, legislative
clarification, and other measures discussed below would be to provide
greater oversight and analysis of significant chemical incidents in the
United States. [See comment 7]
Work of Others:
GAO Recommendation: Consider using the work of other entities, such as
government agencies, companies, and contractors (subject to an
assessment of the quality of their work) to maximize the Board's
limited resources.
CSB Response: The Board will consider using the work of other entities
and contractors to further maximize its limited resources. [See comment
8] In our experience, however, there are limits and pitfalls to the use
of other entities' work. Based on this experience, we respectfully
suggest that the CSB has correctly interpreted its Congressional
mandate by independently investigating major accidents and hazards in
depth, rather than attempting to serve as a clearinghouse for numerous,
disparate, and often superficial reports from other organizations. We
discuss some of our initial concerns with GAO's recommendation below.
[See comment 9]
The Occupational Safety and Health Administration (OSHA) and the
Environmental Protection Agency (EPA) frequently conduct inspections at
accident sites. [See comment 10] However, they have few inspectors
focused and specialized on chemical process safety, and these agencies
typically do not prepare narrative reports describing what happened and
why. Rather, OSHA and EPA may publish citations or notices of
regulatory violations, which may or may not relate to the actual causes
of the accidents. These lists of violations cannot generally be used to
establish and report on the causes of the accidents, as required under
the CSB's authorizing statute. Likewise, the investigations conducted
by state and local police and fire agencies generally focus on
particular inquiries such as the "cause and origin" of a chemical fire,
i.e., a determination of the fuel, location, and ignition source. Such
narrow determinations fall well short of Congress's stated intentions
for the scope of CSB investigations. [Footnote 7]
In addition, OSHA, EPA, state fire marshals, fire departments, and
police clearly have law enforcement and regulatory responsibilities.
Investigations by these agencies necessarily focus on rules violations,
rather than on the overall adequacy of existing rules, standards, and
industry practices. Because of their law enforcement and regulatory
duties, many of these agencies are reluctant to share the results of
their ongoing investigations with the CSB. In fact, during the CSB's
investigation of the BP Texas City disaster, both OSHA and the EPA
asserted in correspondence that they would limit the CSB's access to
their inspection staff and records, citing in part the possibility of
criminal prosecution. Today, more than three years after the BP
accident - and more than a year after the CSB completed its landmark
341-page report - issues of criminal responsibility are still being
litigated in federal court. [See comment 11]
Most companies that experience significant chemical accidents that
cause deaths, injuries, or off-site consequences become involved in
lengthy litigation proceedings. Even the most enlightened corporations
generally produce their own accident investigation reports as part of
their litigation defense strategy - not in an effort to inform other
companies and the public objectively about underlying causes. Moreover,
companies often assert that such reports are protected by legal
privilege. Even if the CSB was able to obtain and rely on such reports
as a primary source of information, it could undermine the credibility
of the CSB's work and lead, in some cases, to incorrectly faulting the
efforts of individual workers and third parties, rather than uncovering
important systemic causes. [See comment 12]
Quality of Accident Data:
GAO Recommendation: Improve the quality of [the CSB 's] accident
screening database by better controlling data entry and periodically
sampling accident data to evaluate its consistency and completeness.
CSB Response: We note that the screening database primarily represents
a compilation of the earliest reports of accidents - including those
from the National Response Center (NRC) and the media - which may
contain inherent inaccuracies. Nonetheless the CSB agrees that it
should take additional steps to prevent errors from being introduced
through incorrect data entry. The CSB will revise its board order on
the incident selection process and consider changes to improve data
accuracy. We plan to consider such measures as additional written
guidance and training for incident screeners; designing an electronic
workflow so that significant changes to the database require
supervisory sign-off; and periodic auditing of screening data for
quality and completeness. In addition we will review the staffing for
the screening program and its overall structure as the CSB develops its
human capital plan. Currently screening is done by junior investigators
as collateral duty on a rotating basis. The CSB lacks any staff solely
dedicated to this task.
Reporting Regulation:
GAO Recommendation: Publish a regulation requiring facilities to report
all chemical accidents, as required by law, to better inform the agency
of important details about accidents that they may not receive from
current sources.
CSB Response: The CSB will publish in the Federal Register a Request
for Information (RFI} concerning a reporting regulation. The RFI will
present various options for rulemaking and seek the views and opinions
of our stakeholders on the best path forward. We intend to publish the
RFI within the next three months. In addition, the detailed plan to
conduct more investigations will include staffing and resource
projections for staff to collect and analyze incident information. [See
comment 13]
We note that the CSB's position has been that a reporting regulation is
not needed for the narrow purpose of notifying the CSB of major
accidents warranting the deployment of investigators, which appears to
be the sole purpose of the CSB's authority to issue a reporting rule.
[Footnote 8] Given the limited number of investigations that the CSB
can conduct, we can and do easily learn what we need to know simply
from monitoring the media and reports from the NRC and NTSB. [See
comment 14]
It is also important to note that the obligation to collect chemical
incident data for the broader purposes identified by GAO appears to lie
elsewhere in the federal government. For example, Congress funds
programs to collect chemical accident data at both EPA and the Agency
for Toxic Substances and Disease Registry. OSHA also collects chemical
incident information. [See comment 15]
Management Accountability and Continuity:
GAO Recommendation: Consider reinstating the position of chief
operating officer, with the delegations of responsibility for
establishing performance goals, holding program managers accountable
for meeting those goals, and demonstrating improvement in the agency's
ability to meet its statutory mandates over time.
CSB Response: The CSB agrees that it is appropriate to consider
establishing a senior executive position to oversee important mission
responsibilities. The CSB will give serious consideration to the
establishment of such a position as part of its development of a
strategic human capital plan.
We note that GAO presented no evidence of a problem by not having a
Chief Operating Officer (COO); rather they simply assert the CSB has
"longstanding, serious, and intractable management problems." This is
in stark contrast to the reality that the CSB's highest impact products
(BP Texas City, Combustible Dust Study, CTA, Baker Panel, and the
Safety Video Program) are from the post-2004 era when there was no COO.
The GAO overlooks the fact that during the five years from 1998 to
2002, the CSB completed a total of 12 investigations but then went on
to complete 35 investigations from 2003 to 2008 - a near tripling of
productivity on a flat budget. [See comment 16]
It is also important to note that the CSB was without a Chairperson
from August 2, 2007 to March 17, 2008, virtually the entire duration of
the GAO's review. Consistent with its protocols, the Board delegated
one Member interim executive and administrative authority to ensure
orderly continuation of functions and duties, and there were no
accountability or continuity issues identified during this period.
Therefore, as the Board has evolved, the concern that the "CSB may not
be able to ensure continuity of performance and accountability when
Board Members and Chairs leave the agency," should be considered in the
context of recent events which suggest otherwise.
Human Capital Issues:
GAO Recommendation: Use the Strategic Management of Human Capital
portion of' the President's Management Agenda as criteria for
developing a comprehensive human capital plan, with input from
investigators that includes specific objectives and performance
measures to improve accountability for results and to assist the agency
in its goal of improving its human capital and infrastructure.
CSB Response: The CSB agrees to use the Strategic Management of Human
Capital portion of the President's Management Agenda (PMA) as a guide
for developing a comprehensive human capital plan. [Footnote 9] The CSB
will also continue to work with the Office of Personnel Management's
(OPM) Small Agencies Human Capital Leadership and Merit System
Accountability Office to develop the human capital plan. In addition,
as recommended by OPM, the CSB will use the "Human Capital Report and
Plan for the CSB's Office of Investigations" developed by the CSB human
capital team in October of 2005 to help guide development of the
comprehensive human capital plan. Developing the plan will be included
in the CSB's FY 2009 action plan.
Matters for Congressional Consideration:
Finally, GAO's draft report raised two specific matters for
Congressional consideration concerning oversight of the CSB. The CSB
supports oversight and agrees that the CSB's authorizing legislation or
the IG Act of 1978 are the proper places to address CSB oversight.
However, the CSB has concerns with the GAO's specific suggestions for
Congressional consideration.
GAO Suggestion: Congress may wish to consider amending the CSB's
authorizing statute or the Inspector General Act of 1978 to permanently
give the EPA's Inspector General the authority to serve as the
oversight body/or the agency.
CSB Comment: The CSB respectfully disagrees with the GAO's suggestion
that the EPA IG is the best, if not only, approach to provide permanent
oversight for the CSB. While the EPA IG is one option for oversight of
the CSB, other Offices of Inspector General are also available, some of
which may be more appropriate for the role. [See comment 17]
There are other alternatives as well. For example, the CSB is modeled
on the NTSB. The NTSB, a much larger agency than the CSB, has never had
and does not have its own Inspector General. Rather, GAO and the
Department of Transportation Inspector General (DOTIG) share oversight
responsibilities. GAO is responsible for broad oversight of the NTSB.
[Footnote 10] DOTIG is Limited "to review only the financial
management, property management, and business operations of the
National Transportation Safety Board." (Emphasis added.) [Footnote 11]
DOTTG actually contracts this function to a third party which it
oversees, so the connection between DOTIG and the NTSB is extremely
limited. [See comment 18]
This model has been established in recognition of the fact that the
NTSB issues recommendations to the Department of Transportation,
similar to the manner in which the CSB issues recommendations to the
EPA. Indeed, Congress has consistently and specifically rejected the
assignment of DOTIG to serve as the Inspector General of the NTSB.
[Footnote 12] The relevant legislative history explains that the
limited nature of the DOTIG's authority was to "ensure that Inspector
General oversight does not undermine the independence of the
NTSB."[Footnote 13] [See comment 19]
Another alternative is a small in-house Inspector General office. Such
a model already exists for about 30 medium-size agencies, such as the
Consumer Product Safety Commission, which are not large enough to have
presidentially appointed IG's. Such an arrangement would appear to be
less costly and more beneficial in the long term than what GAO has
suggested.
GAO Suggestion: As Congress prepares the appropriation of the EPA
Inspector General, it may wish to consider providing the Inspector
General with appropriations and staff allocations specifically for the
audit function of CSB via a direct line in the budget.
CSB Comment: The CSB is concerned that GAO did not adequately consider
different oversight options for the CSB. While we agree that oversight
of every federal agency is appropriate and can be beneficial, it should
be tailored to the size of the agency. In that regard I note that the
CSB currently obtains its financial and information security audits for
about $60,000 a year. [See comment 21]
Thank you for the opportunity to comment on your draft report.
Sincerely,
Signed by:
John S. Bresland:
Chairman & CEO:
The following are GAO's comments to the U.S. Chemical Safety and Hazard
Investigation Board's letter dated August 9, 2008.
GAO Evaluation:
1. We believe this briefing fairly and factually identifies continuing
problems with CSB's governance, management, and oversight that have
continued since we first reported on CSB, in fiscal year 2000.[Footnote
14] We conducted this performance audit in accordance with generally
accepted government auditing standards. Those standards require that we
plan and perform the audit to obtain sufficient, appropriate evidence
to provide a reasonable basis for our findings and conclusions based on
our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
2. While the inspectors general closed these recommendations, their
decision was often based on CSB's commitment to take future actions and
the IG's reserving the right to reopen recommendations. As stated in
the briefing, our analysis shows that CSB has not fully responded to
key recommendations related to (1) investigating more accidents that
meet statutory requirements triggering CSB's responsibility to
investigate, (2) improving the quality of its accident data, (3)
resolving human capital problems, and (4) ensuring accountability and
continuity of management.
3. The 1990 Clean Air Act Amendments establishing CSB contained the
following mandates:
* "The Board shall investigate (or cause to be investigated)�any
accidental release resulting in a fatality, serious injury or
substantial property damage"[Footnote 15] (emphasis added).
* "In no event shall the Board forgo an investigation where an
accidental release causes a fatality or serious injury among the
general public, or had [sic] the potential to cause substantial
property damage or a number of deaths or injuries among the general
public"[Footnote 16] (emphasis added).
As noted in our briefing slides, this language clearly identifies the
accidental releases CSB is required to investigate; investigations are
required for all accidental releases that result, or have the potential
to result, in a fatality, serious injury, or substantial property
damage.
4. While CSB reports that it will seek additional investigation
resources and "will draft a plan for obtaining information on
additional chemical accidents occurring in the United States, and
clearly set forth a risk-based approach to accident selection and
investigation," it does not commit to meet CSB's statutory mandate or
commit to investigating more than six accidents per year. However, CSB
reported that the agency would work with Congress to clarify the issue
of its statutory mandate and, if appropriate, seek an amendment to its
authorizing statute.
Also see comment 3.
5. A more useful benchmark for comparison between CSB and NTSB is to
examine their appropriations and accident investigations. As noted on
slide 15, while NTSB's budget is 8 times CSB's budget, NTSB
investigated 250 times as many accidents. In addition, while CSB notes
that the majority of NTSB's accident investigations were nonfatal, the
majority of accidents CSB screened were also nonfatal, as stated on
slide 14.
CSB also notes that NTSB relies "heavily on the work of FAA." CSB could
similarly rely more on the work of EPA and OSHA and already has
cooperative agreements in place with these agencies to share
information on accidents. The agency currently has memorandums of
understanding (MOU) with both EPA and OSHA with the stated purpose of
establishing "policy and general procedures for cooperation and
coordination between the two Agencies to minimize duplication of
activities." Moreover, the MOUs state the two agencies will "coordinate
incident notification, data and information exchange, training,
technical and professional assistance." The MOU with EPA further states
that "in certain instances, the CSB may decide not to send an
investigation team to the site of a chemical incident. Rather, CSB may
collect incident information from EPA or other on-site agencies
compiled in the course of their own actions." Similar language appears
in the MOU with OSHA.
6. In our view, this approach would not be consistent with CSB's own
authorizing legislation. NTSB's authorizing legislation gives it broad
discretion in determining which accidents in the nonaviation
transportation modes to investigate. For example, NTSB "shall
investigate or have investigated�a highway accident, including a
railroad grade crossing accident, the Board selects in cooperation with
a State[Footnote 17]" (emphasis added). In addition, NTSB's authorizing
legislation requires investigations of "any other accident related to
the transportation of individuals or property when the Board decides"
that certain circumstances are present (emphasis added[Footnote 18]).
CSB's authorizing statute, on the other hand, does not contain any
similar language providing discretion for CSB to determine which
accidental releases to investigate.
CSB's statutory authority is more comparable to the language that
governs NTSB's investigations of civil aviation, railroad, and pipeline
accidents. NTSB is required to investigate railroad accidents with a
fatality or substantial property, railroad accidents that involve a
passenger train, and pipeline accidents with fatalities, substantial
property damage, or significant injury to the environment.[Footnote 19]
Like CSB, NTSB is required to investigate these types of accidents; it
does not have the discretion to choose which to investigate.
Also see comment 3 and 4.
7. Our recommendation is to develop a plan to address the investigative
gap and request the necessary resources from Congress to meet CSB's
statutory mandate or seek an amendment to its statutory mandate.
Also see comment 3 and 6.
8. GAO agrees that there are limitations in using the work of others.
As CSB examines NTSB's work, it may find that there are lessons to be
learned about how to minimize the limitations in using the work of
others. While NTSB uses its authority to solicit the investigative work
performed by others when resources or other considerations prevent it
from deploying to accident sites, in all cases, overall investigative
control--including determination of probable cause--rests with NTSB. As
we reported in 2007, outside experts provide critical assistance to
NTSB investigators. During the course of an investigation, NTSB
supplements its investigative staff through the use of "parties" and
outside contractors when it needs additional support for fact finding
or technical analysis. "Party" participants include individuals,
agencies, companies, and associations that can provide technical
expertise relevant to a specific accident during the fact-finding
phase. 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--both
entities that are likely working with NTSB as parties to the
investigation. Despite such challenges, the party system appears to be
working well; for example, RAND Corporation 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.
In addition, according to NTSB officials, the agency makes a
distinction between fact gathering and analysis. Parties are permitted
to gather facts (evidence) for NTSB, but they are not permitted to
engage in the analysis of that evidence.
9. As noted above, CSB's authorizing statute requires investigations of
all accidental releases that cause, or have the potential to cause, a
fatality, serious injury, or substantial property damage. CSB's
authorizing statute does not specify, that investigations should be
limited to those accidental releases that are "major." In addition,
CSB's authorizing statute grants CSB discretion to "utilize the
expertise and experience of other agencies."[Footnote 20]
Also see comment 3.
10. CSB could use information available from other entities, including
OSHA and EPA, to conduct its own independent analysis of accidents,
although in some cases, CSB may need to supplement information provided
by other entities through follow-up calls, sending investigators to the
scene of the accident, or other means.
Also see comment 8.
11. When CSB examines the work of NTSB, the agency could review how
NTSB obtains information from other public entities pertaining to
ongoing investigations.
Also, see comments 5 and 8.
12. An examination of NTSB's work may provide information about how
NTSB uses its party process to minimize the limitations in using the
work of others.
Also see comments 8 and 11.
13. We recognize that obtaining the views and opinions of CSB's
stakeholders could provide valuable information regarding the
preparation of a reporting regulation. However, the request for
information does not in itself provide assurance that CSB will follow
through and issue a regulation as required by CSB's authorizing
statute. Specifically, the statute provides that the board
"shall�establish by regulation requirements binding on persons for
reporting accidental releases into the ambient air subject to the
Board's investigatory jurisdiction."[Footnote 21] CSB's comments
concerning the need for such a regulation are not relevant because CSB
is legally required to promulgate a regulation. In addition, we
disagree with CSB about the regulation's usefulness. A reporting
regulation would allow CSB to obtain more accurate, complete
information to meet its statutory mandate.
14. As we note in our briefing, information reported by facilities
would be a better source than CSB's current practice of relying mostly
on information from the media, which CSB officials acknowledge is often
inaccurate or incomplete. Our analysis of CSB's accident data showed
that in fiscal year 2007, CSB received 66 percent of its chemical
accident notifications exclusively from the news media. In addition,
CSB's accident database is not just for selection of accidents to
investigate, it is also used to report to Congress and serves as a
historical record of information on chemical accidents that could be
used to identify trends and patterns in chemical accidents and prevent
future accidents.
See also comment 13.
15. The Department of Homeland Security Inspector General (DHS IG)
reported in 2004 that the lack of comprehensive and timely reporting on
chemical accidents in general is a problem the CSB is both positioned
and required to address.[Footnote 22] Citing a 2002 CSB report on
reactive hazards,[Footnote 23] the DHS IG reported that "CSB searched
40 public and private databases and reported that its findings were
limited because existing sources of incident data are inadequate to
identify the number, severity, frequency, and causes of reactive
incidents. CSB's analysis included chemical accident data at EPA and
OSHA.
Also see comments 13 and 14.
16. We introduced the recommendation for reinstating a permanent COO as
one way CSB could begin addressing the management and accountability
problems that we have presented in this briefing. As stated in the
briefing, the difficulties that CSB has experienced in meeting its
mission are largely the result of inadequate management accountability
for addressing long-standing problems. If CSB officials recognize these
long-standing problems and agree that they need to be addressed, then
reinstating a permanent COO could help provide the continuity of
management needed to bring about this change. In addition, former
Chairman Carolyn W. Merritt testified in July 2007 that CSB:
"would benefit�if Congress�provided for a vice chairman to assure the
orderly transition during times when the chair is vacant. Periodic
vacancies in the chair, and the resulting absence of executive
authority, pose a significant risk to the success of the agency. Under
the existing structure, CSB board members cannot serve beyond the
expiration of their five-year terms, and thus vacancies in the chair
and other board seats are all but inevitable." [Footnote 24]
17. While we recognize that alternatives exist for providing CSB with
management oversight, after reviewing various oversight options, we
continue to believe that the EPA IG has several advantages, provides
the best option for oversight, and the oversight authority should be
made permanent. The EPA IG has expertise involving the chemical
management issues that the Board is charged with investigating, has
gained knowledge of CSB's operations and activities in providing the
Board with oversight over the past several years, and, like other IGs,
has the requisite independence provided by the IG Act of 1978 necessary
for reviewing and making recommendations to address long-standing
problems in the Board's management performance.
18. We recognize that Congress provided for a division of
responsibility between the Department of Transportation (DoT) IG and
GAO regarding the oversight of NTSB. However, GAO has largely devoted
its efforts to program evaluations and policy analyses that look at
programs and functions across government and with a longer-term
perspective. On the other hand, IGs have been on the front line of
combating fraud, waste, and abuse within their respective agencies, and
their work has generally concentrated on specific program-related
issues of immediate concern with more of their resources going into
uncovering inappropriate activities and expenditures through an
emphasis on investigations. IGs play a critical role in identifying
mismanagement of scarce taxpayer dollars and could provide, based on
the results of our evaluation, a valuable service for the CSB.
Moreover, as we have stated in the past, we believe that all
significant federal programs and entities should be subject to
oversight by independent IGs.
See comment 17.
19. In response to CSB's point that Congress has "consistently and
specifically rejected" assigning the DoT IG to serve as IG of the NTSB,
we note that the DoT IG's assignment to and GAO annual audit
requirements of the NTSB are recent actions--the DoT IG was assigned to
NTSB in 2000 and GAO assigned in late 2006. As stated in the briefing,
we believe that all significant federal programs and entities should be
subject to oversight by IGs who can provide sound, independent audits
of all significant federal operations and activities. While we
recognize that the Congress took specific actions it felt appropriate
to ensure the independence of NTSB, we note that Congress has not taken
such action with respect to CSB. Furthermore, IGs are independent from
the agency they audit and investigate, and we believe the EPA IG has
the requisite independence from CSB.
See comment 17 and 18.
20. As stated in the briefing, CSB's history of management problems
warrants a level of independent oversight that may be difficult to
achieve by an internal audit function. In addition, the limited
staffing that would reasonably be allocated to this function at an
agency of this size would lack the varied expertise needed to address
these problems.
21. As stated in the briefing, we believe that all significant federal
programs and entities should be subject to oversight by IGs who can
provide sound, independent audits of all significant federal operations
and activities. Given the management problems that our audit revealed,
the need for independent IG oversight is especially pressing. We also
note that these management problems would not be addressed by financial
or information security audits.
See comment 17, 19 and 20.
[End of enclosure]
Footnotes:
[1] S. Rpt. No. 101-228, 1990 U.S.C.C.A.N. 3385, 3615 (1989).
[2] NTSB is required by statute to investigate every civil aviation
accident in the United States and certain railroad, pipeline, and
marine accidents and issue safety recommendations aimed at preventing
future accidents.
[3] GAO, Chemical Safety Board: Improved Policies and Additional
Oversight Are Needed, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO/RCED-00-192] (Washington, D.C.: July 11, 2000).
[4] Joint Explanatory Statement to Accompany the Consolidated
Appropriations Amendment, Division F, at 60.
[5] Pub. L. No. 95-452, 92 Stat. 1101 (codified as amended at 5 U.S.C.
App. 3).
[6] GAO, National Transportation Safety Board: Progress Made,
Management Practices, Investigation Priorities, and Training Center Use
Should Be Improved, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
07-118] (Washington, D.C.: Nov., 22, 2006).
[7] See S. Rpt. No. 101-228, 1990 U.S.C.C.A.N. 3385, 3617-18 (1989)
(stating that, "The Board should take an "all cause" theory....it is
expected that the Board will follow many strands of inquiry....").
[8] See 42 U.S.C. � 7412(r)(6)(C)(iii).
[9] OPM indicated to the CSB that it is not a scored agency under the
PMA and therefore not required to go to the depth a scored agency mast.
However, the CSB will develop the human capital plan using the PMA as a
guide.
[10] See Pub, L. No. 109-443, 120 Stat. 3297, 3299, � 5(a) (2006)
(codified at 49 U.S.C.A. � 1138).
[11] 49 U.S.C. � 1137(a).
[12] The CSB has conducted numerous discussions with NTSB officials in
order to understand why the DOTIG role as the NTSB IG was rejected.
NTSB officials have consistently explained to us that this was to
prevent the appearance or the occurrence of conflicts with DOT
officials to whom the NTSB makes recommendations.
[13] HR. Rep. No. 106-335 at 9 (2000) and S. Rep. 106-386 at 9 (2000).
[14] GAO, Chemical Safety Board: Improved Policies and Additional
Oversight Are Needed (GAO/RCED-00-192, July 11, 2000).
[15] 42 U.S.C. � 7412(r)(6)(C)(i).
[16] 42 U.S.C. � 7412(r)(6)(E).
[17] 49 U.S.C. � 1131(a)(1)(B).
[18] 49 U.S.C. � 1131(a)(1)(F).
[19] 42 U.S.C. � 1131(a)(1).
[20] 42 U.S.C. � 7412(r)(6)(D).
[21] 42 U.S.C. � 7412(r)(6)(C)(iii).
[22] Department of Homeland Security Office of Inspector General, A
Report on the Continuing Development of the U.S. Chemical Safety and
Hazard Investigation Board, OIG-04-04 (Jan. 7, 2004).
[23] U.S. Chemical Safety and Hazard Investigation Board, Improving
Reactive Hazard Management, Sept. 17, 2002.
[24] Testimony of Carolyn W. Merritt, Chairman and Chief Executive
Officer, U.S. Chemical Safety and Hazard Investigation Board before the
U.S. Senate Committee on Environment and Public Works, Subcommittee on
Transportation Safety, Infrastructure Security, and Water Quality, July
10, 2007.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: [email protected]:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, [email protected]:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, [email protected]:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
*** End of document. ***