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


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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

November 2006: 

National Transportation Safety Board: 

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

GAO-07-118: 

GAO Highlights: 

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

Why GAO Did This Study: 

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

What GAO Found: 

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

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

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

What GAO Recommends: 

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

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-118]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Gerald L. Dillingham at 
(202) 512-2834 or dillinghamg@gao.gov. 

[End of Section] 

Contents: 

Letter1: 

Results in Brief: 

Background: 

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

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

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

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: Prior GAO Recommendations to NTSB: 

Appendix III: Additional Analysis of NTSB Safety Recommendations Data: 

Appendix IV: Comments from the National Transportation Safety Board: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

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

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

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

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

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

Table 6: Entities Interviewed by GAO: 

Table 7: Safety Recommendation Data Fields Analyzed: 

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

Figures: 

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

Figure 2: NTSB's Organization: 

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

Figure 4: Components of an NTSB Investigation and Recommendation 
Closeout: 

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

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

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

Figure 8: Leading Practices in Diversity Management: 

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

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

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

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

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

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

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

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

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

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

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

Abbreviations: 

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

United States Government Accountability Office: 
Washington, DC 20548: 

November 22, 2006: 

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

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

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

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

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

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

Results in Brief: 

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

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

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

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

Background: 

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

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

[See PDF for image] 

Source: GAO summary of law, regulations, and policies. 

[End of figure] 

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

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

Mode: Aviation[A]; 
2002: 1,949; 
2002: 1,997; 
2003: 1,870; 
2004: 1,937. 

Mode: Highway; 
2002: 52; 
2002: 45; 
2003: 45; 
2004: 33. 

Mode: Rail; 
2002: 11; 
2002: 9; 
2003: 12; 
2004: 8. 

Mode: Pipeline; 
2002: 1; 
2002: 2; 
2003: 2; 
2004: 1. 

Mode: Hazardous materials; 
2002: 2; 
2002: 1; 
2003: 2; 
2004: 1. 

Mode: Marine; 
2002: 6; 
2002: 6; 
2003: 7; 
2004: 4. 

Source: GAO analysis of NTSB data. 

[A] Aviation accidents include limited investigations in which NTSB 
delegates the gathering of on-scene information to FAA inspectors. 

[End of table] 

NTSB's Organization and Resources: 

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

Figure 2: NTSB's Organization: 

[See PDF for image] 

Source: NTSB. 

[End of figure] 

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

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

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

[End of figure] 

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

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

Training center: Lease value; 
Acquisition value: $23,731,941. 

Training center: Equipment value; 
Acquisition value: 211,485. 

Training center: Furniture value; 
Acquisition value: 347,641. 

Training center: Desktop computers value; 
Acquisition value: 307,353. 

Training center: Training center total value; 
Acquisition value: $24,598,420. 

Training center: Headquarters: Materials lab; 
Acquisition value: $1,590,797. 

Training center: Headquarters: All other headquarters value; 
Acquisition value: 1,862,188. 

Training center: Headquarters total value; 
Acquisition value: $3,452,985. 

Training center: Training center and headquarters total value; 
Acquisition value: $28,051,405. 

Source: GAO analysis of NTSB data. 

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

[End of table] 

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

Investigative Process: 

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

Figure 4: Components of an NTSB Investigation and Recommendation 
Closeout: 

[See PDF for image] 

Source: GAO analysis of NTSB data. 

[A] IIC is the "investigator-in-charge." 

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

[End of figure] 

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

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

Leading Management Practices: 

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

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

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

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

[See PDF for image] 

Source: GAO analysis of NTSB information. 

[End of figure] 

NTSB's Strategic Plan Lacks Certain Performance-Based Elements: 

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

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

[See PDF for image] 

Source: GAO analysis of NTSB information. 

[End of figure] 

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

NTSB Is Partially Following Leading Human Capital Practices: 

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

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

[See PDF for image] 

Source: GAO analysis of NTSB information. 

[End of figure] 

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

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

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

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

NTSB Lacks a Strategic Approach to Training Staff: 

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

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

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

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

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

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

NTSB Is Not Following Most Diversity Management Leading Practices: 

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

Figure 8: Leading Practices in Diversity Management: 

[See PDF for image] 

Source: GAO. 

[End of figure] 

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

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

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

Acquisition Management Has Made Significant Progress in Recent Years: 

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

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

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

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

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

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

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

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

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

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

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

NTSB Lacks a Knowledge Management Program: 

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

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

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

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

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

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

[See PDF for image] 

Source: GAO analysis of legislative, regulatory, and NTSB documents. 

[End of figure] 

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

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

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

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

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

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

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

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

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

[End of figure] 

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

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

External Sources Provide Essential Services during Accident 
Investigations: 

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

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

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

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

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

Year: 1997; 
Aviation: 1; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 0; 
Highway: 0; 
Total: 1. 

Year: 1998; 
Aviation: 1; 
Marine: 1; 
Rail, pipeline, and hazardous materials: 1; 
Highway: 2; 
Total: 5. 

Year: 1999; 
Aviation: 1; 
Marine: 2; 
Rail, pipeline, and hazardous materials: 2; 
Highway: 3; 
Total: 8. 

Year: 2000; 
Aviation: 2; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 1; 
Highway: 1; 
Total: 4. 

Year: 2001; 
Aviation: 0; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 0; 
Highway: 0; 
Total: 0. 

Year: 2002; 
Aviation: 2; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 1; 
Highway: 0; 
Total: 3. 

Year: 2003; 
Aviation: 1; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 0; 
Highway: 1; 
Total: 2. 

Year: 2004; 
Aviation: 1; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 0; 
Highway: 0; 
Total: 1. 

Year: 2005; 
Aviation: 1; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 1; 
Highway: 0; 
Total: 2. 

Year: 2006; 
Aviation: 2; 
Marine: 0; 
Rail, pipeline, and hazardous materials: 0; 
Highway: 1; 
Total: 3. 

Year: Total; 
Aviation: 12; 
Marine: 3; 
Rail, pipeline, and hazardous materials: 6; 
Highway: 8; 
Total: 29. 

Source: GAO analysis of NTSB data. 

Note: Calendar year 2006 includes data through August 2006. 

[End of table] 

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

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

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

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

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

[End of figure] 

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

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

[End of figure] 

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

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

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

NTSB Takes Proactive Steps Outside of Specific Accident Investigations: 

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

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

Year: 2000; 
Number of studies: 1; 
Mode: Aviation(1). 

Year: 2001; 
Number of studies: 1; 
Mode: Aviation (1). 

Year: 2002; 
Number of studies: 0; 
Mode: Not applicable. 

Year: 2003; 
Number of studies: 0; 
Mode: Not applicable. 

Year: 2004; 
Number of studies: 0; 
Mode: Not applicable. 

Year: 2005; 
Number of studies: 2; 
Mode: Aviation (1), pipeline (1). 

Source: GAO analysis of NTSB data. 

[End of table] 

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

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

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

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

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

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

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

Personnel related; 
Fiscal year 2004: $1,011,716; 
Fiscal year 2005: $978,591; 
Percentage difference: -3%. 

Travel; 
Fiscal year 2004: $24,428; 
Fiscal year 2005: $56,912; 
Percentage difference: 133%. 

Space rental[A]; 
Fiscal year 2004: $2,521,440; 
Fiscal year 2005: $2,500,896; 
Percentage difference: -1%. 

Maintenance/repair of buildings; 
Fiscal year 2004: $706,279; 
Fiscal year 2005: $238,203; 
Percentage difference: -66%. 

Miscellaneous government contract services; 
Fiscal year 2004: $2,204,880; 
Fiscal year 2005: $558,540; 
Percentage difference: -75%. 

Office supplies and equipment; 
Fiscal year 2004: $12,939; 
Fiscal year 2005: $153,249; 
Percentage difference: 1,084%. 

Miscellaneous expenses[B]; 
Fiscal year 2004: $29,320; 
Fiscal year 2005: $28,887; 
Percentage difference: -1%. 

Total expenses; 
Fiscal year 2004: $6,511,002; 
Fiscal year 2005: $4,515,278; 
Percentage difference: -31%. 

Earned revenue[C]; 
Fiscal year 2004: $258,760; 
Fiscal year 2005: $634,800; 
Percentage difference: 145%. 

Overall deficit; 
Fiscal year 2004: -$6,252,242; 
Fiscal year 2005: - $3,880,478; 
Percentage difference: -38%. 

Deficit when space rental expense is excluded; 
Fiscal year 2004: - $3,730,802; 
Fiscal year 2005: -$1,379,582; 
Percentage difference: -63%. 

Source: GAO analysis of information from NTSB. 

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

[B] Miscellaneous expenses such as telephone, mail, photography 
services, and printing. 

[C] Earned revenue includes imputed fees for NTSB students. 

[End of table] 

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

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

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

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

[End of figure] 

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

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

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

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

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

[See PDF for image] 

Source: GAO analysis of NTSB information. 

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

[End of figure] 

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

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

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

Several Options Could Increase Revenues or Reduce Costs: 

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

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

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

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

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

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

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

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

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

Conclusions: 

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

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

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

Recommendations for Executive Action: 

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

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

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

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

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

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

Agency Comments: 

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

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

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

Signed by: 

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

[End of section] 

Appendix I: Scope and Methodology: 

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

We reviewed recommendations made by the RAND Corporation[Footnote 68] 
and Booz Allen Hamilton[Footnote 69]and NTSB's responses to those 
recommendations. Both studies set forth recommendations aimed at 
strengthening NTSB's ability to carry out its safety mission. We 
interviewed current and former NSTB board members, senior officials, 
and division managers and selected investigators and writer-editors 
regarding their experience with those practices at NTSB and their 
perceptions of the effectiveness of those practices. We randomly 
selected 17 of the 203 investigators and 8 writer-editors roughly 
evenly across NTSB's four modal offices. The views of these particular 
individuals are not representative of all NTSB investigators and writer-
editors. We also determined NTSB's response to recommendations made by 
the Department of Transportation's Inspector General. We reviewed NTSB 
documents, including strategic, staffing, and performance management 
plans; management advisory e-mails; information regarding the current 
staffing levels; and employees' training plans for 2006. 

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

Table 6: Entities Interviewed by GAO: 

Type: Federal agency; 
Name of entity: Federal Aviation Administration. 

Type: Federal agency; 
Name of entity: Federal Motor Carrier Safety Administration. 

Type: Federal agency; 
Name of entity: Federal Railroad Administration. 

Type: Federal agency; 
Name of entity: National Highway Traffic Safety Administration. 

Type: Federal agency; 
Name of entity: Pipeline and Hazardous Materials Safety Administration. 

Type: Federal agency; 
Name of entity: U.S. Coast Guard. 

Type: Industry or safety organization; 
Name of entity: AFL-CIO. 

Type: Industry or safety organization; 
Name of entity: Airline Pilots Association. 

Type: Industry or safety organization; 
Name of entity: Air Transport Association. 

Type: Industry or safety organization; 
Name of entity: American Association of Railroads. 

Type: Industry or safety organization; 
Name of entity: Association of Flight Attendants. 

Type: Industry or safety organization; 
Name of entity: Brotherhood of Locomotive Engineers and Trainmen. 

Type: Industry or safety organization; 
Name of entity: Brotherhood of Railroad Signalmen. 

Type: Industry or safety organization; 
Name of entity: Commercial Vehicle Safety Alliance. 

Type: Industry or safety organization; 
Name of entity: International Organization of Masters, Mates, and 
Pilots. 

Type: Industry or safety organization; 
Name of entity: Maritime Institute for Research and Industrial 
Development. 

Type: Industry or safety organization; 
Name of entity: Operation Lifesaver. 

Type: Industry or safety organization; 
Name of entity: Regional Airline Association. 

Type: Industry or safety organization; 
Name of entity: Transit Workers Union of America AFL-CIO. 

Type: Industry or safety organization; 
Name of entity: Transportation Communications International Union. 

Type: Industry or safety organization; 
Name of entity: United Transportation Union. 

Source: GAO. 

[End of table] 

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

Table 7: Safety Recommendation Data Fields Analyzed: 

Field: Mode; 
Definition: Mode of transportation, such as aviation, highway, marine, 
pipeline, or rail. 

Field: Recommendation number; 
Definition: Number assigned by NTSB to distinguish safety 
recommendations. 

Field: Status; 
Definition: Status of the recommendation, such as open or closed and 
whether the addressee for the recommendation is taking acceptable or 
unacceptable action towards its implementation. 

Field: Accident date; 
Definition: Date of the accident associated with the safety 
recommendation. 

Field: Date issued; 
Definition: Date the safety recommendation was issued by NTSB to 
addressee(s). 

Field: Date closed; 
Definition: Date NTSB closed the recommendation. 

Field: Addressee; 
Definition: Agency or organization that received the safety 
recommendation from NTSB. 

Field: Addressee status; 
Definition: Status of a specific addressee's response to NTSB's 
recommendation. 

Source: NTSB. 

[End of table] 

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

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

[End of section] 

Appendix II: Prior GAO Recommendations to NTSB: 

Based on our ongoing work as of May 2006, to improve the efficiency of 
agency operations we recommended the Chairman of the National 
Transportation Safety Board take the following eight actions:[Footnote 
70] 

* Improve strategic planning by developing a revised strategic plan 
that follows performance-based practices; developing a strategic 
training plan that is aligned with the revised strategic plan and 
identifies skill gaps that pose obstacles to meeting the agency's 
strategic goals and curriculum that would eliminate these gaps; and 
aligning their organizational structure to implement the strategic plan 
and eliminate unnecessary management layers. 

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

* Develop mechanisms that will facilitate communications from staff- 
level employees to senior management, including consideration of 
contracting out a confidential employee survey to obtain employee 
feedback on management initiatives. 

* Identify better practices in the agency and apply them to all modes. 
Consider such things as using project managers or deputy investigators- 
in-charge in all modes, using incentives to encourage performance in 
report development, and examining the layers of review to find ways to 
streamline the process, such as eliminating some levels of review and 
using concurrent reviews as appropriate. 

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

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

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

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

[End of section] 

Appendix III: Additional Analysis of NTSB Safety Recommendations Data: 

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

[See PDF for image] 

Source: GAO analysis of NTEB data. 

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

[End of figure] 

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

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

[End of figure] 

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

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

[End of figure] 

[This page left intentionally blank] 

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

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

[End of figure] 

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

Mode: Aviation; 
Status: Closed acceptable; 
Year issued: 1996: 140; (78%); 
Year issued: 1997: 105; (83%); 
Year issued: 1998: 91; (68%); 
Year issued: 1999: 60; (70%); 
Year issued: 2000: 90; (63%); 
Year issued: 2001: 50; (61%); 
Year issued: 2002: 21; (53%); 
Year issued: 2003: 22; (29%); 
Year issued: 2004: 6; (8%); 
Year issued: 2005: 2; (6%). 

Mode: Aviation; 
Status: Closed unacceptable; 
Year issued: 1996: 28; (16%); 
Year issued: 1997: 15; (12%); 
Year issued: 1998: 24; (18%); 
Year issued: 1999: 9; (10%); 
Year issued: 2000: 13; (9%); 
Year issued: 2001: 0; (0%); 
Year issued: 2002: 1; (3%); 
Year issued: 2003: 0; (0%); 
Year issued: 2004: 2; (3%); 
Year issued: 2005: 0; (0%). 

Mode: Aviation; 
Status: Open; 
Year issued: 1996: 11; (6%); 
Year issued: 1997: 6; (5%); 
Year issued: 1998: 19; (14%); 
Year issued: 1999: 17; (20%); 
Year issued: 2000: 41; (28%); 
Year issued: 2001: 32; (39%); 
Year issued: 2002: 18; (45%); 
Year issued: 2003: 54; (71%); 
Year issued: 2004: 66; (89%); 
Year issued: 2005: 33; (94%). 

Mode: Aviation; 
Status: Total; 
Year issued: 1996: 179; 100%; 
Year issued: 1997: 126; 100%; 
Year issued: 1998: 134; 100%; 
Year issued: 1999: 86; 100%; 
Year issued: 2000: 144; 100%; 
Year issued: 2001: 82; 100%; 
Year issued: 2002: 40; 100%; 
Year issued: 2003: 76; 100%; 
Year issued: 2004: 74; 100%; 
Year issued: 2005: 35; 100%. 

Mode: Highway; 
Status: Closed acceptable; 
Year issued: 1996: 39; (66%); 
Year issued: 1997: 30; (77%); 
Year issued: 1998: 33; (67%); 
Year issued: 1999: 39; (55%); 
Year issued: 2000: 14; (42%); 
Year issued: 2001: 11; (30%); 
Year issued: 2002: 15; (33%); 
Year issued: 2003: 8; (25%); 
Year issued: 2004: 11; (23%); 
Year issued: 2005: 2; (6%). 

Mode: Highway; 
Status: Closed unacceptable; 
Year issued: 1996: 6; (10%); 
Year issued: 1997: 1; (3%); 
Year issued: 1998: 5; (10%); 
Year issued: 1999: 6; (8%); 
Year issued: 2000: 0; (0%); 
Year issued: 2001: 0; (0%); 
Year issued: 2002: 0; (0%); 
Year issued: 2003: 0; (0%); 
Year issued: 2004: 0; (0%); 
Year issued: 2005: 0; (0%). 

Mode: Highway; 
Status: Open; 
Year issued: 1996: 14; (24%); 
Year issued: 1997: 8; (21%); 
Year issued: 1998: 11;(22%); 
Year issued: 1999: 26; (37%); 
Year issued: 2000: 19; (58%); 
Year issued: 2001: 26; (70%); 
Year issued: 2002: 30; (67%); 
Year issued: 2003: 24; (75%); 
Year issued: 2004: 37; (77%); 
Year issued: 2005: 30; (94%). 

Mode: Highway; 
Status: Total; 
Year issued: 1996: 59; 100%; 
Year issued: 1997: 39; 101%; 
Year issued: 1998: 49; 99%; 
Year issued: 1999: 71; 100%; 
Year issued: 2000: 33; 100%; 
Year issued: 2001: 37; 100%; 
Year issued: 2002: 45; 100%; 
Year issued: 2003: 32; 100%; 
Year issued: 2004: 48; 100%; 
Year issued: 2005: 32; 100%. 

Mode: Marine; 
Status: Closed acceptable; 
Year issued: 1996: 14; (74%); 
Year issued: 1997: 54; (86%); 
Year issued: 1998: 83; (66%); 
Year issued: 1999: 20; (91%); 
Year issued: 2000: 26; (72%); 
Year issued: 2001: 18; (78%); 
Year issued: 2002: 16; (52%); 
Year issued: 2003: 0; (0%); 
Year issued: 2004: 1; (25%); 
Year issued: 2005: 2; (13%). 

Mode: Marine; 
Status: Closed unacceptable; 
Year issued: 1996: 5; (26%); 
Year issued: 1997: 7; (11%); 
Year issued: 1998: 32; (25%); 
Year issued: 1999: 0; (0%); 
Year issued: 2000: 1; (3%); 
Year issued: 2001: 0; (0%); 
Year issued: 2002: 2; (6%); 
Year issued: 2003: 0; (0%); 
Year issued: 2004: 0; (0%); 
Year issued: 2005: 0; (0%). 

Mode: Marine; 
Status: Open; 
Year issued: 1996: 0; (0%); 
Year issued: 1997: 2; (3%); 
Year issued: 1998: 11; (9%); 
Year issued: 1999: 2; (9%); 
Year issued: 2000: 9; (25%); 
Year issued: 2001: 5; (22%); 
Year issued: 2002: 13; (42%); 
Year issued: 2003: 1; (100%); 
Year issued: 2004: 3; (75%); 
Year issued: 2005: 13; (87%). 

Mode: Marine; 
Status: Total; 
Year issued: 1996: 19; 100%; 
Year issued: 1997: 64; 100%; 
Year issued: 1998: 126; 100%; 
Year issued: 1999: 22; 100%; 
Year issued: 2000: 36; 100%; 
Year issued: 2001: 23; 100%; 
Year issued: 2002: 31; 100%; 
Year issued: 2003: 1; 100%; 
Year issued: 2004: 4; 100%; 
Year issued: 2005: 15; 100%. 

Mode: Pipeline; 
Status: Closed acceptable; 
Year issued: 1996: 22; (76%); 
Year issued: 1997: 5; (100%); 
Year issued: 1998: 61; (82%); 
Year issued: 1999: 8; (67%); 
Year issued: 2000: 21; (81%); 
Year issued: 2001: 3; (75%); 
Year issued: 2002: 3; (60%); 
Year issued: 2003: 2; (50%); 
Year issued: 2004: 6; (43%); 
Year issued: 2005: 0; (0%). 

Mode: Pipeline; 
Status: Closed unacceptable; 
Year issued: 1996: 7; (24%); 
Year issued: 1997: 0; (0%); 
Year issued: 1998: 11; (15%); 
Year issued: 1999: 2; (17%); 
Year issued: 2000: 3; (12%); 
Year issued: 2001: 0; (0%); 
Year issued: 2002: 0; (0%); 
Year issued: 2003: 0; (0%); 
Year issued: 2004: 0; (0%); 
Year issued: 2005: 0; (0%). 

Mode: Pipeline; 
Status: Open; 
Year issued: 1996: 0; (0%); 
Year issued: 1997: 0; (0%); 
Year issued: 1998: 2; (3%); 
Year issued: 1999: 2; (17%); 
Year issued: 2000: 2; (8%); 
Year issued: 2001: 1; (25%); 
Year issued: 2002: 2; (40%); 
Year issued: 2003: 2; (50%); 
Year issued: 2004: 8; (57%); 
Year issued: 2005: 5; (100%). 

Mode: Pipeline; 
Status: Total; 
Year issued: 1996: 29; 100%; 
Year issued: 1997: 5; 100%; 
Year issued: 1998: 74; 100%; 
Year issued: 1999: 12; 101%; 
Year issued: 2000: 26; 101%; 
Year issued: 2001: 4; 100%; 
Year issued: 2002: 5; 100%; 
Year issued: 2003: 4; 100%; 
Year issued: 2004: 14; 100%; 
Year issued: 2005: 5; 100%. 

Mode: Railroad; 
Status: Closed acceptable; 
Year issued: 1996: 64; (97%); 
Year issued: 1997: 59; (87%); 
Year issued: 1998: 63; (93%); 
Year issued: 1999: 61; (100%); 
Year issued: 2000: 11; (65%); 
Year issued: 2001: 18; (72%); 
Year issued: 2002: 14; (45%); 
Year issued: 2003: 9; (39%); 
Year issued: 2004: 1; (8%); 
Year issued: 2005: 2; (9%). 

Mode: Railroad; 
Status: Closed unacceptable; 
Year issued: 1996: 2; (3%); 
Year issued: 1997: 3; (4%); 
Year issued: 1998: 4; (6%); 
Year issued: 1999: 0; (0%); 
Year issued: 2000: 0; (0%); 
Year issued: 2001: 0; (0%); 
Year issued: 2002: 0; (0%); 
Year issued: 2003: 1; (4%); 
Year issued: 2004: 0; (0%); 
Year issued: 2005: 0; (0%). 

Mode: Railroad; 
Status: Open; 
Year issued: 1996: 0; (0%); 
Year issued: 1997: 6; (9%); 
Year issued: 1998: 1; (1%); 
Year issued: 1999: 0; (0%); 
Year issued: 2000: 6; (35%); 
Year issued: 2001: 7; (28%); 
Year issued: 2002: 17; (55%); 
Year issued: 2003: 13; (57%); 
Year issued: 2004: 11; (92%); 
Year issued: 2005: 20; (91%). 

Mode: Railroad; 
Status: Total; 
Year issued: 1996: 66; 100%; 
Year issued: 1997: 68; 100%; 
Year issued: 1998: 69; 100%; 
Year issued: 1999: 61; 100%; 
Year issued: 2000: 17; 100%; 
Year issued: 2001: 25; 100%; 
Year issued: 2002: 31; 100%; 
Year issued: 2003: 23; 100%; 
Year issued: 2004: 12; 100%; 
Year issued: 2005: 22; 100%. 

Source: GAO analysis of NTSB data. 

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

[End of table] 

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

[See PDF for image] 

Source: GAO analysis of NTSB data. 

Note: Recommendations were issued calendar years 1995-2001. 

[End of figure] 

[End of section] 

Appendix IV: Comments from the National Transportation Safety Board: 

National Transportation Safety Board: 
Washington, D.C. 20594: 
Office of the Chairman: 

November 15, 2006: 

Gerald L. Dillingham, Ph. D. 
Director, Civil Aviation Issues Physical Infrastructure: 
Government Accountability Office: 
441 G Street, NW, Room 2T23B: 
Washington, DC 20548: 

Dear Dr. Dillingham: 

Thank you for the opportunity to comment on your proposed report 
entitled National Transportation Safety Board: Progress Made, Yet 
Management Practices, Investigation Priorities, and Training Center Use 
Should Be Improved (GAO-07-118). In general, we agree with your 
recommendations and are pleased that your report recognizes the number 
of significant improvements we have made to strengthen our management 
practices. 

During this 12 month management study (December 2005-November 2006) 
between the Government Accountability Office (GAO) and the National 
Transportation Safety Board (NTSB), the NTSB has worked diligently to 
support your audit, and has been fully cooperative and completely 
forthcoming with information. We have made all NTSB staff available at 
the convenience of the GAO auditors, and we met with the auditors on 
more than 70 occasions. We responded expeditiously to all requests for 
information and we have furnished more than 200 documents and related 
data to support the auditors in their review. Further, your team of 
auditors has joined NTSB investigators on-site during one of our local 
general aviation accident investigations, and we provided complete and 
ready access to the highest leadership levels within the agency. My 
senior management team and I have not only welcomed the GAO review, but 
we generally agree with the 5 recommendations presented by the GAO. We 
believe that the GAO's recommendations will assist NTSB in our ongoing 
efforts to improve NTSB management practices, investigation priorities, 
and training center usage, and they will help us ensure that we execute 
our important mission efficiently and effectively. 

As you are aware, in August 2006, 1 was sworn in as the Chairman of the 
NTSB, and I had been serving as Acting Chairman since March 2005. Also 
in March 2005, the NTSB top leadership changed, and with this change 
came a renewed focus on improving the organizational development, 
communications, and strategic planning necessary to develop a robust, 
efficient, and dynamically led organization. Although many challenges 
remain, we are confident that the best practices that GAO is 
recommending, can help NTSB strengthen our management practices, 
investigation processes, and training center usage. 

For example, for the first time in six years, the NTSB has in place a 
strategic plan, and we are currently making strides to evolve and 
improve that plan. Senior executives now have performance plans that 
are linked to our strategic plan, and both report production output and 
project tracking are greatly improved. Although the NTSB has more work 
to do in the area of human capital, we now have a human capital 
forecast and a staffing plan, which represent our first steps into a 
broad program of human capital planning, and we are building the 
framework for a targeted training program for our staff. Agency-wide 
communications have improved in both quality and quantity, and the 
information flow to the Board Members has also significantly improved. 

In 2006, as directed by Congress, the NTSB developed a business plan 
for the Training Center. Even with this plan, like you, we understand 
that we still face the challenge of increasing the utilization of the 
Training Center. We are taking additional steps to address this issue 
and to improve the utility and cost effectiveness of the facility. 

Finally, in 2003, the NTSB recognized that the Training Center lease 
should have been recorded as a capital lease rather than an operating 
lease. Capitalizing the full net present value of the lease created a 
funding deficiency for fiscal year 2001. The NTSB disclosed the 
resultant noncompliance with the Anti-Deficiency Act during fiscal year 
2004. Since 2004, the NTSB has been working to bring the agency into 
compliance with the Anti-Deficiency Act. As we have noted before, the 
NTSB, in consultation with the GAO and the Office of Management and 
Budget, requested Congress to take the appropriate steps to address the 
Anti-Deficiency. 

Thank you again for providing NTSB with the opportunity to comment on 
your proposed report and for acknowledging the management improvements 
that have been made at the NTSB. 

Sincerely, 

Signed by: 

Mark V. Rosenker: 
Chairman: 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

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

Staff Acknowledgments: 

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

[End of section] 

Related GAO Products: 

Enterprise Architecture: Leadership Remains Key to Establishing and 
Leveraging Architectures for Organizational Transformation. GAO-06- 
831. Washington, D.C.: August 14, 2006. 

Managing for Results: Enhancing Agency Use of Performance Information 
for Management Decision Making. GAO-05-927. Washington, D.C.: September 
9, 2005. 

Human Capital: Selected Agencies Have Opportunities to Enhance Existing 
Succession Planning and Management Efforts. GAO-05-585. Washington, 
D.C.: June 30, 2005. 

21st Century Challenges: Reexamining the Base of the Federal 
Government. GAO-05-325SP. Washington, D.C.: February 1, 2005. 

Diversity Management: Expert-Identified Leading Practices and Agency 
Examples. GAO-05-90. Washington, D.C.: January 14, 2005. 

Results-Oriented Government: GPRA Has Established a Solid Foundation 
for Achieving Greater Results. GAO-04-594T. Washington, D.C.: March 31, 
2004. 

Human Capital: A Guide for Assessing Strategic Training and Development 
Efforts in the Federal Government. GAO-04-546G. Washington, D.C.: March 
1, 2004. 

Information Technology Management: Governmentwide Strategic Planning, 
Performance Measurement, and Investment Management Can be Further 
Improved. GAO-04-49. Washington, D.C. January 2004. 

Human Capital: Key Principles for Effective Strategic Workforce 
Planning. GAO-04-39. Washington, D.C.: December 11, 2003. 

Results-Oriented Government: Using GPRA to Address 21st Century 
Challenges. GAO-03-1166T. Washington, D.C.: September 18, 2003. 

Results-Oriented Cultures: Implementation Steps to Assist Mergers and 
Organizational Transformations. GAO-03-669. Washington, D.C.: July 2, 
2003. 

Results-Oriented Cultures: Modern Performance Management Systems Are 
Needed to Effectively Support Pay for Performance. GAO-03-612T. 
Washington, D.C.: April 1, 2003. 

Results Oriented Cultures: Creating a Clear Linkage between Individual 
Performance and Organizational Success. GAO-03-488. Washington, D.C.: 
March 14, 2003. 

Human Capital: Effective Use of Flexibilities Can Assist Agencies in 
Managing Their Workforces. GAO-03-2. Washington, D.C.: December 6, 
2002. 

A Model of Strategic Human Capital Management. GAO-02-373SP. 
Washington, D.C.: March 15, 2002. 

Managing for Results: Using GPRA to Assist Oversight and 
Decisionmaking. GAO-01-872T. Washington, D.C.: June 19, 2001. 

Executive Guide: Creating Value through World-class Financial 
Management. GAO/AIMD-00-134. Washington, D.C.: April 1, 2000. 

FOOTNOTES 

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

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

[3] GAO-06-801T. 

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

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

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

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

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

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

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

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

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

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

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

[15] GAO-06-801T. 

[16] Pub. L. No. 103-62. 

[17] GAO-06-801T. 

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

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

[20] GAO-06-801T. 

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

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

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

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

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

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

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

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

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

[30] GAO-06-801T. 

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

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

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

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

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

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

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

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

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

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

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

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

[43] FAA can also conduct separate investigations looking into 
compliance issues with federal aviation laws and regulations. 49 U.S.C. 
§40113(a). 

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

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

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

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

[48] The wreckage is used for certain courses. 

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

[50] GAO-06-801T. 

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

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

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

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

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

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

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

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

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

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

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

[62] [Hyperlink, http://www.gsa.gov/aircraftpolicy]. 

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

[64] 49 U.S.C. § 1113(b)(1)(I). 

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

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

[67] GAO-06-801T. 

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

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

[70] GAO-06-801T. 

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