This is the accessible text file for GAO report number GAO-06-801T 
entitled 'National Transportation Safety Board: Preliminary 
Observations on the Value of Comprehensive Planning, and Greater Use of 
Leading Practices and the Training Academy' which was released on May 
26, 2006. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to Webmaster@gao.gov. 

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

Testimony: 

Before the Subcommittee on Aviation, Committee on Commerce, Science and 
Transportation, U.S. Senate: 

United States Government Accountability Office: 

GAO: 

For Release on Delivery Expected at 9:00 a.m. EDT: 

Wednesday, May 24, 2006: 

National Transportation Safety Board: 

Preliminary Observations on the Value of Comprehensive Planning, and 
Greater Use of Leading Practices and the Training Academy: 

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

GAO-06-801T: 

GAO Highlights: 

Highlights of GAO-06-801T, a report to Subcommittee on Aviation, 
Committee on Commerce, Science and Transportation. 

Why GAO Did This Study: 

The National Transportation Safety Board (NTSB) is a relatively small 
agency that plays a vital role in transportation safety and has a 
worldwide reputation for investigating accidents. With a staff of about 
400 and a budget of $76.7 million in fiscal year 2006, NTSB 
investigates all civil aviation accidents in the United States, and 
significant accidents in railroad, highway, marine, and pipeline; and 
issues safety recommendations to address issues identified during 
accident investigations. To support its mission, NTSB built a training 
academy, which opened in 2003 and provides training to NTSB 
investigators and others. It is important that NTSB use its resources 
efficiently to carry out its mission and maintain its preeminence. This 
testimony, based on ongoing work for this committee, addresses the 
extent to which NTSB follows leading practices in selected management 
areas, addresses challenges in completing accident investigations and 
closing safety recommendations, and generates sufficient revenues to 
cover costs at its academy. 

What GAO Found: 

NTSB has recently made progress in following leading management 
practices, but overall has a mixed record. For example, NTSB has 
improved its financial management by hiring a Chief Financial Officer 
and putting controls on its purchasing activities, which should address 
past problems with unapproved purchases. However, NTSB lacks a full 
cost accounting system, which would inform managers of the resources 
spent on individual investigations and provide data to balance office 
workload. NTSB has also begun to develop a performance management 
system that should eventually link each individual’s performance to the 
agency’s strategic goals and objectives. However, the performance 
management system will not be fully functional until NTSB has developed 
a strategic plan with results-oriented goals and objectives and 
specific strategies for achieving them, which are lacking in the 
current strategic plan. Other areas, such as human capital and 
communications, partially follow leading practices. 

Table: Extent to Which NTSB Is Following Leading Practices in Selected 
Management Area: 

Management Area: Strategic Planning; 
Extent to which NTSB follows leading practices: Leading practices are 
minimally followed; 

Management Area: Performance management; Extent to which NTSB follows 
leading practices: Leading practices are partially followed; 

Management Area: Human capital; 
Extent to which NTSB follows leading practices: Leading practices are 
partially followed; 

Management Area: Financial Management; Extent to which NTSB follows 
leading practices: Leading practices are mostly followed; 

Management Area: Communications; 
Extent to which NTSB follows leading practices: Leading practices are 
partially followed. 

Source: GAO's Analysis of NTSB Information. 

[End of Table] 

While NTSB is accomplishing its accident investigation mission, it 
faces challenges that affect the efficiency of the report production 
and recommendation close out processes. NTSB routinely takes longer 
than 2 years to complete major investigations. Several factors may 
affect the length of report production, including several revisions of 
draft reports through multiple layers of the organization. In addition, 
the processes for federal transportation agencies to implement NTSB’s 
safety recommendations and for NTSB to change the status of 
recommendations are lengthy, paper-based, and labor intensive. While 
Department of Transportation officials have been working with NTSB to 
find acceptable means of implementing its recommendations, they cite 
the lengthy rule-making process as a challenge to speedy 
implementation. 

For fiscal years 2004 and 2005, NTSB’s academy did not generate 
sufficient revenues to cover the costs of providing training. As a 
result, those portions of the academy’s costs that were not covered by 
the revenues from tuition and other sources—approximately $6.3 million 
in fiscal year 2004 and $3.9 million in fiscal year 2005—were offset by 
general appropriations to the agency. While NTSB has taken action to 
generate revenue from other sources, such as renting academy space for 
conferences, it does not have a marketing plan that seeks to optimize 
opportunities for additional revenues at the academy. 

What GAO Recommends: 

Based on completed work to date, GAO recommends, among other things, 
that NTSB develop a revised strategic plan that follows performance-
based practices, develop a full cost accounting system, and develop a 
marketing plan for the academy. NTSB agreed with GAO’s recommendations. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-801T]. 

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] 

Mr. Chairman and Members of the Subcommittee: 

We are pleased to be here today to discuss the reauthorization of the 
National Transportation Safety Board (NTSB). NTSB is a relatively small 
agency that plays a vital role in transportation safety. With a staff 
of about 400 and a budget of $76.7 million in fiscal year 2006, NTSB is 
charged with investigating every civil aviation accident in the United 
States and significant accidents in the other modes--railroad, highway, 
marine, and pipeline--,determining the probable cause of these 
accidents and issuing recommendations to address safety issues 
identified during accident investigations. NTSB has gained a worldwide 
reputation as a preeminent agency in conducting transportation accident 
investigations. Since 1967, it has issued 1,340 major accident 
investigation reports, over 130,000 brief accident reports, and made 
over 12,000 safety recommendations. To support its mission, NTSB built 
a training academy that opened in 2003 and provides training to NTSB 
investigators and other transportation safety professionals, including 
those from foreign countries. It is critical that the agency uses its 
resources in an efficient manner to carry out its safety mission and 
maintain its preeminent position. For this reason, you asked us to 
conduct a comprehensive review of NTSB's management functions such as 
strategic planning, human capital management, and mission-critical 
investigation activities. My testimony today is based on our ongoing 
work for you, and it addresses the extent to which NTSB is (1) 
following leading practices in selected management areas, (2) 
addressing challenges in completing accident investigations and closing 
safety recommendations, and (3) generating sufficient revenues to cover 
costs at its academy. We will be reporting additional results of our 
ongoing work to the committee later this year. 

In summary: 

* While NTSB has recently made progress in following leading management 
practices, its overall record is mixed. For example, NTSB generally 
follows leading practices in the area of financial management. Over the 
last several years, NTSB has hired a Chief Financial Officer and 
improved its financial management by putting controls on its purchasing 
activities, which should address past problems with unapproved 
purchases with government credit cards. However, NTSB lacks a full cost 
accounting system, which would inform managers of the resources spent 
on individual investigations and provide data to help assure balanced 
office workload. Other areas, such as performance management, human 
capital, and communications, partially follow leading practices. For 
example, NTSB has begun to develop a performance management system that 
should eventually link each individual's performance to the agency's 
strategic goals and objectives. However, the performance management 
system will not be fully functional until NTSB has a strategic plan 
with results-oriented objectives and specific strategies for achieving 
them, which are lacking in the current strategic plan. In the area of 
human capital management, NTSB has recently developed a draft staffing 
plan that addresses the agency's skills and competencies needs and 
includes strategies to increase the number of investigators and thereby 
strengthen the agency's ability to carry out its transportation safety 
mission. However, the draft plan does not address organizational 
structure or the balance between supervisory and nonsupervisory 
positions. While NTSB has recently taken positive steps to improve 
communications from senior management to the staff--such as 
periodically sending e-mail to all staff to share information on new 
developments and policies--the agency does not regularly hold general 
staff meetings or undertake anonymous surveys to obtain employee 
feedback. 

* NTSB is accomplishing its accident investigation mission, but it 
faces challenges that affect the efficiency of the report production 
and recommendation close-out processes. In terms of accomplishing its 
mission, since its inception in 1966, NTSB has investigated over 
134,000 transportation accidents, and 82 percent of its recommendations 
have been implemented, or acceptable progress toward implementation has 
been made. However, investigations are often--sometimes necessarily-- 
lengthy; NTSB routinely takes longer than 2 years to investigate major 
accidents. Lengthy investigations, combined with lengthy processes for 
federal agencies to regulate and industries to implement NTSB's safety 
recommendations, can work against the goal of improving transportation 
safety. One factor that adds to the duration of investigations is that 
when new investigations are launched, inspectors are pulled from 
working on previous accidents to work on new ones. Other factors that 
may affect the duration of report production include the multiple 
revisions of draft investigation reports at different levels in the 
organizations and resource issues. NTSB has recently taken several 
actions that may help shorten report development time, such as 
reemphasizing its policy on holding report development meetings to 
obtain early buy-in on report messages and holding modal directors 
accountable for specific issuance dates. We also identified practices 
in certain offices, such as the use of a project manager or deputy 
investigator-in-charge to handle report production, which may improve 
the efficiency of report development if used by all modal offices as 
they all are similar in what they do. The processes for implementing 
NTSB's safety recommendations, and for NTSB to change the status of 
recommendations are also lengthy and labor intensive. As a result, 
unsafe conditions may continue to exist until federal transportation 
agencies, and ultimately, transportation industries, fully implement 
the recommendations, and the extended period it takes to change the 
status of recommendations ties up NTSB's scarce resources. As of May 
2006, 305 of the 852 open recommendations have been in open status for 
5 years or more. While Department of Transportation (DOT) officials 
have been working with NTSB to find acceptable means of implementing 
its recommendations, they cite the lengthy rule-making process as a 
challenge to speedy implementation. In addition, the process that NTSB 
uses to change the status of safety recommendations is paper-based, 
labor intensive, and relies on a series of sequential reviews that can 
take months to complete. As a result, resources within NTSB are 
inefficiently used and DOT agency officials told us they remain unaware 
whether their response has been accepted or not accepted. 

* For fiscal years 2004 and 2005, NTSB's academy did not generate 
sufficient revenues to cover the costs of providing training. As a 
result, those portions of the academy's costs that were not covered by 
the revenues from tuition and other sources--approximately $6.3 million 
in fiscal year 2004 and $3.9 million in fiscal year 2005--were offset 
by general appropriations to the agency. Although there is no statutory 
requirement that revenues from NTSB's academy generate sufficient 
revenues to cover the costs, NTSB was encouraged in the Senate report 
accompanying the Fiscal Year 2006 DOT Appropriations Act to be more 
aggressive in imposing and collecting fees to cover the costs. While 
NTSB has taken action to generate revenue from other sources, such as 
renting academy space for conferences, it does not have a business plan 
that seeks to optimize opportunities for additional revenues at the 
academy. Additionally, NTSB is missing opportunities to find other uses 
for academy space. For example, during fiscal year 2005, less than 10 
percent of the total classroom space was used. About 14 percent of the 
academy students in fiscal year 2005 were NTSB employees. However, in 
2006, NTSB employees are scheduled to take 97 percent of their 
requested training from sources other than the academy, such as DOT's 
Transportation Safety Institute. The academy is not utilized more by 
NTSB staff, in part, because the agency has not developed a core 
curriculum for its staff, which it could then offer at the academy. 
Furthermore, many academy courses are similar to those taught 
elsewhere, which may affect the agency's ability to attract non-NTSB 
students. 

Background: 

NTSB was established in 1966 as an independent government agency 
located within the newly formed DOT.[Footnote 1] In 1974, Congress made 
NTSB completely separate from DOT.[Footnote 2] NTSB's principal 
responsibility is to promote transportation safety by investigating 
transportation accidents, determining the probable cause, and issuing 
recommendations to address safety issues identified during accident 
investigations. Unlike other transportation agencies, such as the 
Federal Aviation Administration (FAA), NTSB does not have the authority 
to promulgate regulations to promote safety, but makes recommendations 
in its accident reports and safety studies[Footnote 3] to other 
agencies that have such regulatory authority. The federal agencies that 
receive NTSB recommendations include the DOT's FAA, Federal Highway 
Administration (FHWA), Federal Motor Carrier Safety Administration 
(FMCSA), Federal Railroad Administration (FRA), Federal Transit 
Administration (FTA), National Highway Traffic Safety Administration 
(NHTSA), Pipeline and Hazardous Materials Safety Administration 
(PHMSA), and the U.S. Coast Guard. NTSB also makes recommendations to 
others, such as state transportation authorities and industries. As 
figure 1 indicates, NTSB has varying degrees of flexibility in its 
statutory mandate, as it pertains to initiating an investigation. By 
statute, NTSB has limited discretion in deciding which aviation 
accidents to investigate and the greatest amount of discretion to 
investigate highway accidents. 

Figure 1: NTSB's Investigative Policy by Mode: 

[See PDF for image] 

[End of figure] 

NTSB is comprised of a five member board--a chairman, vice chairman, 
and three members--appointed by the President with the advice and 
consent of the Senate.[Footnote 4] The chairman is NTSB's chief 
executive and administrative officer. As of March 2006, the board was 
supported by a staff of 396, which includes 210 investigators assigned 
to four modal offices--aviation; highway; marine; and rail, pipeline, 
hazardous materials. (See fig. 2.) The agency is headquartered in 
Washington, D.C., and maintains 10 field offices nationwide and a 
training academy in Ashburn, Virginia, in suburban Washington, D.C. In 
recent years, the agency has shrunk in size due to budget constraints, 
which it has largely dealt with by using attrition to downsize the 
staff. In 2003, NTSB had 438 full time employees compared with the 
current level of 396. During the same period, the number of full-time 
investigators decreased from 234 to 210. NTSB's modal offices vary in 
size, with the aviation office having 125 employees; the rail, 
pipeline, and hazardous materials office having 38; the highway office 
having 30; and the marine office having 16 employees as of May 2006. An 
additional 42 employees work in the Office of Research and Engineering, 
which provides technical, laboratory, analytical, and engineering 
support for the modal investigation offices. For example, it is 
responsible for interpreting data recorders, creating accident computer 
simulations, and publishing general safety studies. NTSB's budget 
increased from $62.9 million in fiscal year 2001 to $76.7 million in 
fiscal year 2006, or about 22 percent. After adjusting for inflation, 
this represents an increase of about 9 percent. The President has 
requested $79.6 million for NTSB in fiscal year 2007. 

Figure 2: NTSB's Organization: 

[See PDF for image] 

[End of figure] 

Since 1966, NTSB has investigated over 124,000 aviation accidents and 
over 10,000 surface transportation accidents. Figure 3 shows the total 
number of aviation investigations that NTSB has undertaken over the 
past 6 years and the degree to which NTSB was involved in the 
investigations. NTSB lacks the resources to conduct on-scene 
investigations of all aviation accidents. As a result, for general 
aviation accidents, NTSB delegates the gathering of on-scene 
information to FAA investigators, as allowed by statute.[Footnote 5] In 
these limited investigations, FAA sends the accident information to 
NTSB, and NTSB then determines a probable cause for the accident. In 
addition, NTSB participates in the investigations of foreign aviation 
accidents in conformance with Annex 13 of the International Civil 
Aeronautics Organization Treaty. These investigations involve a U.S. 
carrier or U.S.-built aircraft, or occur at the request of a foreign 
government. NTSB aviation investigators told us that there is often 
significant value in participating in such investigations; the findings 
often have safety implications for U.S. carriers, since most foreign 
airlines use U.S.-made aircraft, engines, and other parts and multiple 
foreign air carriers operate within the United States. 

Figure 3: NTSB Involvement in Aviation Accidents, Fiscal Years 2000- 
2005: 

[See PDF for image] 

Note: Limited investigations are those in which NTSB delegates the 
gathering of on-scene information to FAA inspectors. 

[End of figure] 

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

Through our work government wide we have identified a number of key 
functional areas and leading practices in areas that are important for 
managing an agency. This testimony focuses on NTSB's performance in 
five key functional areas--strategic planning, performance management, 
human capital, financial management, and communications--and how NTSB's 
practices compare to leading practices in those areas. As illustrated 
in figure 4, NTSB generally is following leading practices in financial 
management, only minimally following leading practices in strategic 
planning, and has mixed results for the other functions. Much of NTSB's 
progress toward following leading practices is due to recent management 
initiatives. The report we will be issuing later this year will provide 
additional information on NTSB's performance relative to these five 
management functions, as well as information technology, acquisition 
management (including the agency's use of contracting), knowledge 
management, and capital decisionmaking. 

Figure 4: Extent to Which NTSB Is Following Leading Practices in 
Selected Management Areas: 

[See PDF for image] 

[End of figure] 

NTSB's Strategic Plan Lacks Certain Performance-Based Elements and 
Performance Management Plans Closely Follow Leading Practices but are 
not Fully Functional: 

The Congress and the President have encouraged better management of 
federal agencies by means such as results-oriented strategic planning, 
but NTSB's strategic plan generally does not follow performance-based 
practices. Without effective short-and long-term planning, federal 
agencies risk delivering programs and services that may or may not meet 
the nation's most critical needs. The Government Performance and 
Results Act of 1993 (GPRA)[Footnote 6] and guidance contained in the 
Office of Management and Budget's (OMB) Circular A-11, provide 
performance-based strategic planning guidelines. GPRA was intended to 
achieve several broad purposes, including improving federal program 
effectiveness, accountability, and service delivery, and enhancing 
congressional decision making by providing more objective information 
on program performance. GPRA requires federal agencies to develop 
strategic plans in which they define their missions, establish results- 
oriented goals, and identify the strategies that will be needed to 
achieve those goals. For instance, GPRA requires strategic plan updates 
at least every 3 years, and requires that agencies set objectives and 
goals that are specific outcomes that the organization wishes to 
accomplish (called outcome-related objectives). 

To its credit, in December 2005, NTSB issued a strategic plan for the 
years 2006 through 2010, which was the first time the agency had a 
strategic plan in 6 years. In developing that plan, senior agency 
officials told us that they modeled their plan on examples from other 
federal agencies with similar structure and mission, such as the 
Federal Communications Commission. We compared NTSB's strategic plan to 
selected elements required by GPRA. (See fig. 5.) 

Figure 5: Extent to Which NTSB's Strategic Plan Follows GPRA Elements: 

[See PDF for image] 

[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. One 
goal states "NTSB will maintain its response capacity for investigation 
of accidents and increase its analysis of incidents." An objective of 
that goal is to "continuously assess the most robust and efficient 
approaches to accident investigation." Although such a goal is 
important for the safety of the transportation industry, this and the 
other three goals and related objectives are not measurable. As a 
result, it will be difficult for NTSB and others to determine if the 
goals have been achieved. 

In addition, the plan lacks specific strategies for achieving those 
goals. According to GPRA, the strategies should include a description 
of the operational processes, skills and technology, and the resources 
required to meet the goals and objectives. Since NTSB's strategic plan 
lacks such a description, it does not align staffing, training, or 
other human resource management to strategic goals. That is, the plan 
does not explicitly explain how NTSB will use its resources to meet its 
mission and goals. While the plan explains that each program office has 
its own objectives linked to the agency's goals and objectives, the 
plan contains no information to understand how each office contributes 
to those goals and objectives. In addition, NTSB's strategic plan does 
not describe how the performance goals contained in the annual 
performance plan are related to the general goals and objectives in the 
strategic plan, as required by GPRA. 

GPRA also requires federal agencies to provide a description in their 
strategic plans of the program evaluations used in establishing or 
revising general goals and objectives and a schedule for future program 
evaluation. NTSB's strategic plan lacks this information. As a result 
of having no program evaluations, it is unclear how or whether NTSB 
reviews its efforts to identify strengths it can maximize and 
weaknesses it should address. In developing a strategic plan, GRPA 
requires agencies to consult with Congress and other stakeholders. We 
have previously reported that other stakeholders of federal agencies 
include state and local governments, other federal agencies, interest 
groups, and agency employees. NTSB's strategic plan does not mention 
consultation with any stakeholders in its development. Furthermore, 
board members and agency staff told us that they had no involvement in 
the development of the strategic plan. Some current and past board 
members additionally stated that they believed that their involvement 
would be beneficial in providing a strategic vision for the agency. 
NTSB's senior management told us they expect to revise the strategic 
plan in the near future and contacted us regarding assistance to 
develop a more comprehensive, results-oriented plan as part of this 
study. 

NTSB has begun to develop a performance management system that should 
eventually link each individual's performance throughout the agency to 
the agency's strategic goals and objectives. We have reported that 
performance management systems are crucial for agencies because if 
developed properly they allow employees to make meaningful 
contributions that directly contribute to agency goals.[Footnote 7] 
NTSB has developed a comprehensive performance management plan for 
Senior Executive Series (SES) employees that links individual 
performance to strategic goals. Furthermore, the plan states that NTSB 
will link performance management with the agency's results-oriented 
goals and set and communicate individual and organizational goals and 
expectations. This plan establishes individual performance criteria and 
the appraisal process. The appraisal process defines performance 
standards and explains performance elements that determine individual 
ratings. Because NTSB recognizes in this plan the importance of 
aligning organizational performance with individual performance and 
contributions to the agency's mission, the performance management plan 
is a step in the right direction. 

Along with the SES plan, NTSB issued in August 2005 a performance plan 
for its overall workforce, which includes some elements of linking 
individual performance to organizational goals. However, without having 
results-oriented goals in the strategic plan itself, neither of the two 
performance management plans are fully functional. That is, until 
NTSB's goals are more fully articulated in the strategic plan, it will 
be impossible for staff to know whether their performance contributes 
to meeting those goals. As with the strategic plan, NTSB staff was not 
involved in the development of the performance plan, and there was no 
mechanism for employee feedback after the plan was initially developed. 
Employee involvement provides greater assurance that policies are 
accepted and implemented because employees had a stake in their 
development. 

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

NTSB developed a draft agencywide staffing plan in December 2005 that 
follows several leading practices but lacks a workforce deployment 
strategy that considers the organizational structure and its balance of 
supervisory and non-supervisory positions. Existing strategic workforce 
planning tools and models suggest that certain principles should be 
followed in strategic workforce planning, such as determining the 
agency's skills and competencies needs; involving stakeholders (e.g., 
management and employees) in the planning process; and developing 
succession plans to anticipate upcoming employee retirement and 
workforce shifts.[Footnote 8] Further, in workforce deployment, it is 
important to have human capital strategies to avoid excess 
organizational layers and to properly balance supervisory and 
nonsupervisory positions.[Footnote 9] NTSB's draft staffing plan 
addresses the agency's skills and competencies needs and includes 
strategies to deal with workforce shifts. For example, the staffing 
plan proposes to increase the number of investigative staff by 21, 
which will help with the agency's resource needs. In addition, while 
some stakeholders (i.e., managers) were involved in the planning 
process, employees were not included. As we mentioned previously in 
this testimony, employee input provides greater assurance that policies 
are accepted and implemented because employees have a stake in their 
development. 

To develop the staffing plan, each modal office director submitted to 
NTSB's Managing Director an ideal staff size for his office, including 
additional slots for investigators. The increase in investigative staff 
is consistent with requests by modal offices to enhance their ability 
to conduct their investigative mission. Managers told us that current 
staffing constraints inhibited their ability to conduct more accident 
investigations and indicated an increase in staff would be helpful. For 
example, directors of the highway and rail/pipeline offices told us 
they could not initiate investigations on more than two accidents at a 
time because they lacked sufficient investigative staff to do 
more.[Footnote 10] The modal office directors' request for staff 
resulted in a total agency allotment of 455 full time equivalents 
(FTEs) plus 20 co-op positions. The Managing Director reduced this 
number to 404, which corresponds to NTSB's current funding level of 
395, allowing for attrition and turnover. The Managing Director's 
allocation resulted in a proposed increase of 21 investigators 
agencywide and a proposed reduction of certain staff positions to 
accommodate the increase in investigators. This increase in 
investigative staff is consistent with a recommendation by RAND 
Corporation, which evaluated NTSB's accident investigation process and 
workload in 1999.[Footnote 11] To help implement the realignment, 
senior managers told us that they would like to transition some 
existing administrative and support staff with appropriate background 
and training into investigator roles where possible. The draft plan set 
a target date of May 2006 to begin creating developmental opportunities 
for staff to transition to investigative roles and to develop reduction 
strategies for staff that fall outside the staffing plan. 

NTSB Lacks a Strategic Approach to Training Staff: 

Training is another key area of human capital management. It is 
important for agencies to develop a strategic approach to training its 
workforce, which involves establishing training priorities and 
leveraging investments in training to achieve agency results; 
identifying specific training initiatives that improve individual and 
agency performance; ensuring effective and efficient delivery of 
training opportunities in an environment that supports learning and 
change; and demonstrating how training efforts contribute to improved 
performance and results.[Footnote 12] NTSB has not developed a 
strategic training plan, nor has it identified the core competencies 
needed to support its mission and a curriculum to develop those 
competencies. As a result of not having a core curriculum that is 
linked in this manner, NTSB lacks assurance that the courses that staff 
take provide the technical knowledge and skills necessary for them to 
be competent for the type of work they perform. 

Financial Management Is Improved, but NTSB Lacks a Full Cost Accounting 
System: 

Sound financial management is crucial for responsible stewardship of 
federal resources.[Footnote 13] In recent years, NTSB has made 
significant progress in improving its financial management. In March 
2001, NTSB hired a Chief Financial Officer who has emphasized the 
importance of sound financial management based on best practices. 
Similar to private sector companies, government agencies are required 
to report their financial condition in publicly available financial 
statements. As a result of actions taken by NTSB, the agency received 
an unqualified or "clean" opinion from independent auditors on its 
financial statements for the fiscal years ending September 30 for the 
years 2003, 2004, and 2005. The audit report concluded that NTSB's 
financial statements presented fairly, in all material respects, the 
financial position, net cost, changes in net position, budgetary 
resources, and financing in conformity with generally accepted 
accounting principles for the three years. NTSB has also improved its 
purchasing and contracting activities after identifying problems in 
those areas in 1999. In 2001, DOT's Office of Inspector General (DOTIG) 
reviewed the agency's contracting and procurement activities and 
recommended that NTSB institute accountability and controls in its 
purchase card program as well as other purchasing activities. As a 
result of this and another DOTIG audit,[Footnote 14] NTSB has taken a 
number of initiatives to improve its purchasing and contracting 
activities. For example, NTSB restructured its purchase card system and 
guidelines to address problems, such as unrestrained and unapproved 
purchases on government credit cards. NTSB hired a manager of the 
contracting function to manage the agency's acquisition function and 
implement the DOTIG recommendations. In our full report, we will 
analyze some of these initiatives in more detail. 

In 2000, RAND recommended that NTSB develop systems that would allow 
the agency to better manage its resources by permitting full-cost 
accounting[Footnote 15] of all agency activities.[Footnote 16] To 
accomplish this, RAND recommended putting in place a timekeeping 
system, in which individual project numbers were assigned to each 
investigation and support activities such as training. With this 
information, project managers could better understand how staff 
resources were utilized and project workload could be actively 
monitored by the Managing Director. NTSB has begun to implement this 
recommendation by upgrading a software system in November 2005 that 
tracks employee annual leave and sick leave. However, the system is not 
being fully utilized to track the number of hours staff spend on each 
investigation. Also, this system is not used to track time staff spend 
in training or at conferences. As a result, RAND's previous conclusion 
that "NTSB managers have little information they can use to plan the 
utilization of staff resources or manage staff workloads properly" 
remains current. 

Communications from Senior Management to Staff have Increased and 
Communications Among Offices is Generally In Place, but Upwards 
Communications Mechanisms Are Lacking: 

We have identified useful practices related to managing employees that 
include seeking and monitoring employee attitudes, encouraging two-way 
communication between employees and management, and incorporating 
employee feedback into new policies and procedures.[Footnote 17] 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 it is communicating information to staff. For example, 
the Managing Director periodically sends "management advisory" e-mail 
to all staff that share information such as policy changes or new 
developments at the agency. However, we found no formal processes that 
encouraged two-way communication, such as town hall meetings, regular 
staff meetings, or anonymous employee surveys; or incorporated employee 
feedback into policy-making. 

The 23 investigators and writer editors with whom we spoke had mixed 
views on the effectiveness of communications within the 
agency.[Footnote 18] The four investigators from one modal office that 
we spoke with told us that they are pleased to now hear about policy 
changes at the agency, but said that there is too much reliance on the 
Internet for these communications. They also told us that although they 
believe the increased communications are positive, they found it 
difficult to find the time to read the material and still conduct their 
regular investigative duties. The four investigators that we spoke with 
from another modal office agreed that staff meetings occur infrequently 
and that they do not receive information on new policies from their 
managers. Further, they said that new policies or agency issues are not 
discussed with staff prior to issuance, and there was no formal 
mechanism to provide feedback during the policies' development. In the 
past, regular formal meetings occurred between union leadership and 
senior NTSB management, which allowed for such input, but that practice 
ceased. Although formal communication processes from the staff level to 
management are lacking, informal e-mail communications do take place 
occasionally between staff and senior management. 

Communication and collaboration across offices at all levels can 
improve an agency's ability to carry out its mission by providing 
opportunities to share best practices and helping to ensure that any 
needed input is provided in a timely manner. We found that 
communication and collaboration between the Research and Engineering 
office and the modal offices appears to be regular. This is shown by 
the inclusion of Research and Engineering staff as core members of 
major investigative teams. Also, our review of workload in the Research 
and Engineering office shows a large number of projects that support 
all modes, and a Research and Engineering manager told us that his 
office frequently interacts with investigative staff. 

In contrast, NTSB lacks processes that would allow investigators and 
writer editors to communicate across the modal offices regarding the 
investigative process and other issues, according to staff we spoke to. 
The four investigators that we spoke with from one modal office told us 
that they are isolated from the rest of the agency and that lessons 
learned are not shared across offices. The investigators from another 
modal office told us that they are on permanent teams that share the 
same priorities in completing accident analysis, which enhances 
communication and teamwork in the office. In addition, in previous 
years, all writer editors were located in one group and reported 
directly to the Managing Director. Now, each modal office has its own 
staff of writers and editors. While they have retained personal working 
relationships from when they were located in the same office, four of 
the eight writer editors we spoke with said that they no longer share 
information with each other regularly.[Footnote 19] As a result, 
efficiencies and lessons learned that investigators and writer editor 
staff in one office might develop might not be shared with other 
offices. However, NTSB officials pointed out that every 6 months writer 
editors have the opportunity to meet with the publications specialist 
for training and to exchange information. 

NTSB Is Accomplishing Its Accident Investigation Mission, but 
Opportunities Exist to Gain Efficiencies: 

While NTSB is accomplishing its accident investigation mission, it 
faces challenges that affect the efficiency of the report production 
and recommendation close-out processes. In terms of accomplishing its 
mission, since its inception, NTSB has investigated over 134,000 
transportation accidents. Eighty-two percent of its recommendations 
have been "accepted," a term NTSB uses to include recommendations that 
recipients have said they would implement as well as those that have 
already been implemented. Figure 6 shows that highway recommendations 
have the highest acceptance rate and marine recommendations have the 
lowest. 

Figure 6: Recommendations and Acceptance Rates of Recommendations by 
Mode, 1967-May 2006: 

[See PDF for image] 

[End of figure] 

NTSB Investigations Are Often Lengthy, in Part Because Investigators 
Must Launch New Investigations Before Completing Ongoing 
Investigations: 

Investigations have four phases--the "launch," fact finding, analysis, 
and report production. After a report is issued and recommendations 
made, the progress of implementing the recommendations is tracked 
during a fifth close-out phase. Figure 7 describes these phases. 

Figure 7: Components of an NTSB Investigation and Recommendation Close 
Out: 

[See PDF for image] 


[A] AIIC is the "investigator in charge." 

[B] A 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] 

Investigations are often lengthy and sometimes necessarily so. NTSB 
routinely takes longer than 2 years to complete major aviation 
investigations. For example, the total time to complete major aviation 
investigations has increased from an average of about 1.25 years in 
1996 to an average of almost 3.5 years in 2006. (See fig. 8.) In 2004, 
NTSB contracted with Booz Allen Hamilton to examine and make 
recommendations to improve the report development process and the 
recommendation close-out process. Booz Allen Hamilton[Footnote 20] 
reported that the average time to complete major investigations across 
all the modes was either 1.8 months or 1.9 months for 4 out of 5 
years.[Footnote 21] Lengthy investigations, combined with lengthy 
processes for federal agencies to develop regulations based on those 
recommendations and industries to implement the recommendations can 
work against the goal of improving transportation safety. 

Figure 8: Average Duration of Major Aviation Investigations, 1996- 
2006: 

[See PDF for image] 

Note: Several complex, lengthy investigations were completed in 2000, 
including the crash of TWA flight 800, which took over 4 years to 
complete. 

[End of figure] 

One factor that adds to the duration of investigations is that when new 
investigations are launched, investigators are pulled from working on 
previous accidents to work on new ones. For example, when a major 
commercial aviation accident occurs, an NTSB "go team" is dispatched 
from Washington D.C., usually within hours of notification of the 
accident. In such cases, the team members must leave the investigations 
they had been working on to begin fact-finding on the new accident. In 
the cases of rail and highway accidents, NTSB investigators must also 
arrive quickly on scene to gather information because the accident 
scenes will be cleared quickly so that traffic can resume. The manager 
of one department told us that all of his ongoing reports would be 
delayed by 2 months if a sudden launch were to occur. The number of 
major investigations that are ongoing for each mode is shown in figure 
9. 

Figure 9: Number of Ongoing Major Investigations by Mode, As of 
February 2006: 

[See PDF for image] 

Note: This table does not include limited aviation investigations, in 
which FAA has the primary fact-finding role. 

[End of figure] 

Writing and Report Production Is a Bottleneck in the Process: 

Another reason for the expansive time frame for accident investigations 
is that reports receive multiple revisions at different levels in the 
organization, including the office directors and the Managing 
Director's office, prior to going to the board members for final voting 
and approval of the draft report. An investigation report typically 
goes through the following reviews: the modal office, the Office of 
Research and Engineering, the Executive Secretariat, the Office of 
Safety Recommendations, the Office of General Counsel, the deputy 
managing director, the Managing Director's office, and each board 
member and the Chairman. For any review, there may be multiple 
iterations. Eleven investigators and 6 writer editors told us that the 
review process often results in improved clarity for report 
recommendations.[Footnote 22] However, investigators and writer editors 
also told us that they believe the levels of management review and 
approval for written products are excessive. All eight writer editors 
agreed that the reviews by the Executive Secretariat's office, which 
services a quality assurance function, was a bottleneck for getting 
products approved. They told us that it is common for correspondence 
and other products to be delayed in this office for 1 week or more, 
which they viewed as excessive. While it may be a reasonable 
expectation for short products, such as correspondence, to be reviewed 
in less than a week, that expectation may not be reasonable for 
reports. Booz Allen Hamilton confirmed multiple iterations of review as 
the draft was routed through numerous offices. On average Booz Allen 
Hamilton found that there were 7 levels of reviews within a given modal 
office that resulted in an average of 28 separate reviews. A senior 
NTSB official stated that the many levels of review were needed to get 
the appropriate perspectives from relevant offices that had been 
involved in report development, such as the Research and Engineering 
Office and Safety Recommendation Office. The official also noted that 
the process can be streamlined on a case-by-case basis in which the 
usual process of sequential reviews is replaced with concurrent 
reviews. The NTSB official told us that there are no explicit criteria 
for determining when the streamlined process could be used. 

NTSB staff with whom we spoke reported that resource issues contributed 
to other bottlenecks. For example, four writer editors pointed out that 
NTSB has only one final layout and typesetting person. As of May 2006, 
the final layout process had a backlog of approximately 10 reports that 
have been approved for issuance at board meetings but have not yet been 
published. NTSB adopts about 2 reports a month and issues on average 4 
reports a month. In addition, some investigators have the perception 
that the workload of writer editors is another bottleneck. For example, 
one investigator told us that he submitted draft reports to the senior 
writer editor in September 2005, and as of April 2006, no additional 
writing had been done on his project. Writer editors from each modal 
office told us they typically worked on five or more products at one 
time. 

Certain Agency Practices May Help Shorten Report Development: 

NTSB has recently taken several actions that, along with potentially 
better practices in one modal office, may help shorten report 
development time. First, in response to a recommendation by Booz Allen 
Hamilton to gain management's buy-in to the report message before 
writing the report and thereby reduce the number of review iterations, 
NTSB management has reemphasized its policy for report development 
meetings. NTSB has a long-standing order that calls for holding message 
development meetings with internal stakeholders who will be reviewing 
the report prior to report writing. According to a senior NTSB 
official, however, the agency had stopped following that policy before 
Booz Allen Hamilton conducted its study in 2004. The official further 
stated that subsequent to that recommendation, NTSB's managing director 
sent a memorandum reminding staff to follow the policy. While NTSB has 
no data on whether the message development meetings are actually taking 
place, officials told us that the managing director's recent emphasis 
on these meetings was resulting in more of them occurring than in 
previous years. 

Second, since the spring of 2005, NTSB has initiated production 
meetings with senior management with the goal of reducing the duration 
of investigations. These meetings occur every 2 weeks and focus on 
report development and production. NTSB modal directors are held 
accountable for a specific issuance date within a six month planning 
window prior to issuing a report. During the biweekly meetings, the 
directors discuss with NTSB's Managing Director and senior executives 
their progress and commitments to complete the investigations. The 
meetings result in a production schedule that is available for 
subsequent review. The modal directors stated that they believe the new 
system is effective in reducing the duration of investigations; however 
because these meetings began so recently, it is too early to evaluate 
their effectiveness. 

Third, the highway office--which has the swiftest rate of accident 
investigation completion--uses a concept called a "project manager," 
who serves as a supervisory writer editor and interface between the 
investigative staff and the writer editor staff. As a result, the 
project manager assumes some of the report development roles typically 
supported by the investigators-in-charge. In comparison, investigators-
in-charge in the marine and rail, pipeline, and hazardous materials 
offices submit a draft report to the writer editor, who then edits and 
sometimes substantially rewrites the report. In aviation, investigators-
in-charge do not write reports, but rather writer editors develop the 
final report from interim technical reports drafted by specialists on 
the team. Booz Allen Hamilton recommended that all modes use a project 
manager or deputy investigator-in-charge so that the expertise of staff 
can be used more fully. In addition, such a practice might alleviate 
some of the workload issues that writer editors face as they complete 
multiple reports. NTSB managers told us that they agree with this 
recommendation, but they have not implemented it or developed any 
milestones for implementation. 

Fourth, the highway safety office uses an incentive system for 
performance on developing reports. Booz Allen Hamilton reported the 
highway safety office rewards staff with a cash bonus for meeting key 
deadlines for producing accident reports. Again, the study recommended 
that the highway program be used as a model for the other modal 
offices. The study further recommended that the incentive program be 
slightly modified so that the incentives are based on delivering 
reports before deadlines, rather than meeting deadlines. In that way, 
the average time standard would be tightened and the overall report 
development time would be shortened. According to NTSB officials, they 
are currently examining how to implement improved awards and incentive 
programs that will result in improved quality and timeliness of report 
products. 

Safety Recommendations Close-out Process Is Time Consuming for Several 
Reasons: 

The processes for federal transportation agencies to implement NTSB's 
safety recommendations, and for NTSB to change the status of 
recommendations it has made, are also lengthy because of complex 
processes involving many players. As of May 2006, 305 of NTSB's 852 
open recommendations had been open for 5 years or more. Lengthy 
processes for federal agencies to develop regulations to implement 
NTSB's safety recommendations and industries to comply can work against 
the goal of quickly improving transportation safety. In addition, the 
lengthy, paper-based process for changing the status of recommendations 
ties up NTSB's scarce resources. 

The length of time that NTSB recommendations remain open is due, in 
part, to challenges faced by federal transportation agencies in 
implementing those recommendations, particularly those that require 
changes to federal regulations, which take many years to complete. DOT 
modal officials with whom we spoke cited a lengthy rule-making process, 
which includes budgeting and allocating resources to develop the 
proposed regulation, drafting and receiving comments on proposed rules, 
and waiting for the industry's subsequent response to implement the 
final rule. For example, TWA flight 800 crashed off Long Island in July 
1996; NTSB issued safety recommendations pertaining to explosive fuel 
tanks in December 1996. NTSB adopted the accident report with further 
recommendations to FAA to reduce flammable vapors in aircraft fuel 
tanks in 2000; FAA issued a notice of proposed rule to address this 
recommendation in November 2005; the comment period for the notice 
ended on March 23, 2006. Thus, 10 years after the crash, the final rule 
has not been issued. Federal transportation officials also said the 
failure to satisfy a cost-benefit analysis might impede the 
implementation of NTSB recommendations. Although NTSB is required to 
only consider the safety implications of its recommendations and not 
consider the cost factors, if a proposed regulation is not cost 
beneficial, it cannot be approved by OMB. 

Federal officials with whom we spoke at DOT, which receives the bulk of 
NTSB recommendations, indicated that they have been working with NTSB 
to find acceptable means of implementing recommendations. The process-
-recently called Safety With a Team--is designed for NTSB and federal 
agencies to work in cooperation to address open recommendations and 
implement needed safety improvements. NTSB and DOT officials told us 
that this process contributed to the closing of many recommendations. 
However, the process is not used with the Coast Guard, which has the 
lowest rate--74 percent--for accepting NTSB recommendations among the 
modes, as mentioned previously. According to a Coast Guard official we 
spoke with, the Coast Guard believes that it has an acceptable rate for 
closing NTSB recommendations and that it does not intend to act on 
recommendations that it deemed unnecessary. 

NTSB recognizes that open recommendations can have serious safety 
implications for the transportation industry. To spur implementation, 
the agency also publishes a "most wanted" list of what it considers the 
most serious safety concerns. For example, in 2000 NTSB added to its 
most wanted list the need to improve the safety of motor carrier 
operations. NTSB recommended that FMCSA prevent motor carriers from 
operating if they put vehicles with mechanical problems on the road or 
unqualified drivers behind the wheel. As recently as May 2006, NTSB 
issued an additional recommendation that FMCSA "establish a program to 
verify that motor carriers have ceased operations after the effective 
date of revocation of operating authority." 

The process that NTSB uses to change the status of or close out safety 
recommendations is paper-based, labor intensive, and relies on a series 
of sequential reviews; this process can take between 6 and 12 weeks. As 
a result, NTSB is delayed in communicating with agencies on whether 
NTSB considers the actions that have been taken to address the 
recommendation are sufficient to accept the recommendation. 
Consequently, agencies remain unaware that their response has been 
accepted or not accepted. And in the case of DOT, this lack of 
information affects its ability to accurately report annually to 
Congress on the status of implementing NTSB's recommendations in all 
its modal administrations.[Footnote 23] 

The process of closing recommendations is managed by NTSB's Safety 
Recommendation Office, which has responsibility for maintaining a 
recommendations database and administering the paper flow to change the 
status of recommendations. Adding complexity to the process--which NTSB 
calls the "mail control process"--is the fact that there are 12 
separate categories of recommendations status. The 12 categories are 
listed in figure 10, which also shows the percentage of recommendations 
in each category as of May 1, 2006. 

Figure 10: Status Categories for Recommendations Issued From 1967 to 
May 1, 2006: 

[See PDF for image] 

Note: NTSB issued 12,471 recommendations from 1967 to May 1, 2006. 

[End of figure] 

The process begins when NTSB receives documentation from the 
recommendation recipient that would change the recommendation's status. 
The Safety Recommendation Office generates paper folders and supervises 
a process that is summarized in figure 11. This process involves 
multiple, sequential approvals starting from the Safety Recommendation 
Office, to the modal offices and Research and Engineering Office, to 
the Managing Director's office, to the board members for final 
approval. Since none of these reviews happen concurrently, some 150 
folders are in process at any given time, according to the director of 
the Safety Recommendations Office. There are no electronic 
communications or approvals throughout the process. In its study of 
NTSB, Booz Allen Hamilton identified this as an inefficient process. 
Officials at NTSB agree that efficiencies could be gained in this 
process and are considering eventually computerizing a number of 
processes such as this one. The agency expects to develop such plans 
after hiring a chief information officer later this year. 

Figure 11: NTSB's Recommendation Close-Out Process: 

[See PDF for image] 

[End of figure] 

NTSB's Academy Does Not Generate Sufficient Revenues to Cover Costs and 
Is Not Fully Utilized: 

Although there is no statutory requirement that revenues from NTSB's 
academy would generate sufficient revenues to cover the costs, in July 
2005, NTSB was encouraged in the Senate report accompanying the Fiscal 
Year 2006 DOT Appropriations Act to be more aggressive in imposing and 
collecting fees to cover the costs.[Footnote 24] The academy generates 
revenues through tuition fees, space rental to other agencies for 
events such as conferences, and contracts with federal agencies that 
would allow them to use academy space for "continuity of operations" in 
emergency situations. To the extent that NTSB maximizes the use of the 
academy, it can produce additional revenues that may help cover costs. 

Academy Costs Have Exceeded Revenues: 

For the first 2 full years of operation, fiscal years 2004 and 2005, 
NTSB's academy did not generate sufficient revenues to cover the costs 
of providing training, as shown in table 1. As a result, those portions 
of the academy's costs that were not covered by the revenues from 
tuition and other sources--approximately $6.3 million in fiscal year 
2004 and $3.9 million in fiscal year 2005--were offset by general 
appropriations to the agency. The salaries and other personnel related 
expenses associated with NTSB investigators and managers teaching at 
the academy, which would be appropriate to include in academy costs, 
are not included in table 1 because NTSB told us that it does not 
choose to account for expenses in that manner. In addition, NTSB lacks 
a full cost-accounting system that would facilitate doing so. The table 
shows expenses directly associated with the academy and does not 
include an allocation of agency wide supporting services, such as the 
Managing Director's office, information technology, human resources, 
and legal support. Some of the expenses during these 2 years were one- 
time expenses--such as over $125,000 for furniture and equipment 
(included in table 1 as office supplies for fiscal year 2005) and 
$499,000 to move the wreckage of the TWA flight 800 airplane from 
storage near the crash site in New York to the academy (included in the 
table as miscellaneous government contract services in fiscal year 
2004). Space rental is a fixed annual expense of about $2.5 million. 
When that fixed expense is excluded from academy expenses, the 
remaining operating expenses exceeded revenues by about $3.7 million in 
fiscal year 2004 and about $1.4 million the subsequent year. 

Table 1: Direct Expenses and Revenues for the NTSB Academy, Fiscal 
Years 2004 and 2005 (unaudited): 

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

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

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

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

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

Office supplies; 
FY 2004: $12,939; 
FY 2005: $153,249; 
Percentage difference: 1084%. 

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

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

Earned revenue; 
FY 2004: $258,760; 
FY 2005: $634,800; 
Percentage difference: 145%. 

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

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

Source: NTSB. 

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

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

[End of table] 

In addition, while some courses presented during the first 2 years of 
academy operation did not recover the costs that NTSB attributes to 
them, revenues from other courses exceeded the cost. Of the 49 class 
sessions provided at the academy in fiscal years 2004 and 2005, 
revenues from 14 sessions, all of which occurred in fiscal year 2005, 
did not recover their cost, while revenues from the remaining sessions 
exceeded the cost.[Footnote 25] According to the academy's deputy 
manager, courses are only expected to generate enough revenues to 
offset the costs specifically attributed to the course, with some 
additional allocation for research and development of other programs 
and, if possible, other academy costs. Accordingly, tuition prices are 
determined by estimating those costs (such as course material, 
contracted instructors and their travel expenses) and dividing that 
cost by the projected class size. Costs such as the building lease, 
maintenance, building security, and academy personnel are not allocated 
to the costs of individual courses.[Footnote 26] In addition, 
consideration is given to setting tuition at a level that is 
competitive with similar courses by other institutions and that is not 
prohibitively high for prospective students from government agencies, 
according to the academy official. 

Other sources of revenue are needed for NTSB to be able to recover the 
full costs of the academy. For fiscal year 2004, over $12,000 in 
revenue (about 5 percent of total revenues) was collected from sources 
other than course fees to cover some of those costs. For fiscal year 
2005, the revenue from other sources increased to over $91,000 (about 
14 percent of total revenues). Other sources of income during these 2 
years included renting space to other organizations, such as the 
Society of Automotive Engineers, George Washington University, and the 
National Association of State Boating Law Administrators for meetings, 
conferences, and boat storage. In addition, NTSB has contracted with 
two agencies--the Federal Energy Regulatory Commission and the Virginia 
Circuit Courts--for continuity of operations. According to NTSB 
officials, it has explored this option with other organizations, but 
has not found others who will pay a yearly retainer for the 
service.[Footnote 27] While NTSB has taken action to generate revenue 
from other sources, it does not have a business plan or marketing 
strategy that seeks to optimize opportunities for additional revenues. 
According to the academy's deputy manager, NTSB plans to develop a 
business plan. The agency, however, has no timeframes for doing so. 

Our analysis of the academy lease indicates that NTSB has the 
flexibility to use the facility in other ways to generate revenues or 
potentially reduce costs. For example, the lease does not preclude NTSB 
from subletting unused space to other users. Since certain space is 
already configured as classrooms and the academy is located in an 
academic setting on George Washington University's suburban Virginia 
campus, it may be possible to market space to academic users. 
Furthermore, NTSB is not precluded by its academy lease or its lease 
for headquarters space in Washington, D.C., from relocating some 
headquarters staff to the Virginia facility. The lease for the office 
space in Washington, D.C., expires in 2011. Such a move, however, would 
incur one-time costs that include relocating staff, moving furniture 
and equipment, reconfiguring space and utilities as well as recurring 
travel costs for staff who must travel between the two locations. Such 
costs would have to be weighed against the reduced cost of leasing less 
space in Washington, D.C. 

Academy Classrooms Are Significantly Underutilized: 

NTSB has not maximized the use of the facility, which could generate 
additional revenues that may help cover costs.[Footnote 28] We estimate 
that, overall, less than 10 percent of the total classroom space was 
used during fiscal year 2005.[Footnote 29] As shown in figure 12, none 
of the five classrooms were used for 21 weeks in fiscal year 2005. In 
addition, at any given time, no more than three classrooms were in use. 
Figure 12 shows the days in which classroom space was used for 31 class 
sessions and 12 other events, such as workshops and seminars by 
organizations that rented the space during fiscal year 2005. 

Figure 12: Utilization of Classrooms by Academy Classes and Other 
Events, Fiscal Year 2005: 

[See PDF for image] 

Note: Bars indicate classroom use. For example, two stacked bars 
indicate that two classrooms were in use on a particular day. 

[End of figure] 

While a relatively small percentage of the academy's students have been 
NTSB staff, the agency is taking efforts to increase their enrollment 
at the academy. About 20 percent of the academy's approximately 1,000 
students[Footnote 30] in fiscal year 2004 were NTSB staff, and about 14 
percent of the 1,400 students in fiscal year 2005 were NTSB staff. Over 
the 2 years, about 400 NTSB students[Footnote 31] attended 38 of the 49 
class sessions conducted at the academy during fiscal years 2004 and 
2005. (See fig. 13) NTSB is making efforts to have staff more fully 
utilize the facility. In fiscal year 2004, 1 of 18 sessions was only 
for NTSB investigators; in fiscal year 2005, 5 of 31 sessions were only 
for NTSB investigators.[Footnote 32] While increasing the use of the 
academy by NTSB staff would reduce the costs of sending them to 
external training, it is important that NTSB not reduce the number of 
external, paying students in the process. 

Figure 13: Number of NTSB and Non-NTSB Students, Fiscal Years 2004 and 
2005: 

[See PDF for image] 

[End of figure] 

NTSB staff receive most of their training from outside the academy, 
which may be due to the courses lacking the subject matter that they 
require. Our analysis of staff training requests for fiscal year 2006 
showed that 97 percent of all training is expected to be from external 
sources and the remaining training from NTSB's academy. NTSB staff have 
requested external training being provided by organizations that 
include FAA's Transportation Safety Institute, the University of 
Southern California, the U.S. Department of Agriculture, and Kettering 
University for training in subjects such as human factors in aviation 
safety, turbine engine investigation, or automotive design and safety. 
Training requests cover other specialties such as helicopter training, 
flight training currency for pilots, technical writing, supervisory and 
management skills, and industry conferences. Investigators and writer 
editors with whom we spoke had positive views on the quality of academy 
training courses but provided several reasons for not taking further 
courses there. Ten of the 23 investigators and writer editors we 
interviewed told us that they had taken (or taught) courses at the 
academy and thought the courses were excellent;[Footnote 33] none of 
the investigators and writer editors had anything negative to say about 
the quality of any academy course. However, none of the staff we talked 
with had plans to attend academy training in fiscal year 2007. One 
reason noted for this situation was the remoteness of Ashburn, 
Virginia, from their residences. Another reason was the lack of courses 
on new transportation technologies and the skills and competencies 
needed by an investigator-in-charge. Eight investigators told us that 
they find workshops by manufacturers, such as aircraft and automobile 
manufacturers, more valuable to their work than academy training. 

The academy is not utilized more by NTSB staff, in part, because the 
agency has not developed a core curriculum for its staff that could 
then be offered at the academy, as mentioned previously in this 
testimony. The academy only offers one course that is required for NTSB 
staff---a 2-week course on aviation accident investigation that is 
required for new NTSB investigator staff. The deputy manager of the 
academy told us that the academy plans to eventually offer more 
internal training covering subjects such as management skills, 
retirement, and computers.[Footnote 34] However, no milestones or 
specific plans have been established for that effort. 

Although most students at the academy are from outside NTSB, several 
factors can affect the agency's ability to attract additional outside 
students. First, the lack of a business or marketing plan may be 
affecting NTSB's ability to fully utilize the academy. Second, academy 
training is similar to training provided by other institutions. FRA, 
FAA, and PHMSA officials told us that their investigators do not attend 
NTSB training because similar training is provided in-house by DOT's 
Transportation Safety Institute. For example, an FAA investigator told 
us that new investigators take a basic accident investigation course at 
the Transportation Safety Institute and subsequently take mid-career 
follow-up courses there. Furthermore, our comparison of NTSB's fiscal 
year 2006 curriculum with that of several other institutions that teach 
courses on accident investigations showed that other institutions 
offered courses similar to 12 of NTSB's 19 courses. For example, DOT's 
Transportation Safety Institute offers basic courses on aviation and 
bus accident investigations, and the University of Southern California 
offers a course on human factors related to accident investigations. 

Additional Issues Concerning the Academy: 

You asked that we provide information concerning the academy's use of 
NTSB investigators as instructors and NTSB's compliance with the Anti- 
Deficiency Act, with regard to its accounting for its academy lease. 
Concerning the first issue, academy courses are taught by a combination 
of academy staff, NTSB investigators and managers, and contractors. Use 
of investigators as instructors is limited and is likely to have little 
impact on investigators' overall workload. During fiscal year 2005, 51 
NTSB investigators or managers taught at the academy. On average they 
spent an estimated 22 hours to prepare for and teach courses. (See fig. 
14.) 

Figure 14: Length of Time NTSB Investigators Spent Teaching and 
Preparing to Teach Academy Courses and the Length of Time All Other 
Instructors Spent Teaching, Fiscal Year 2005: 

[See PDF for image] 

Note: Other instructors include NTSB academy staff, volunteers, and 
contract instructors from outside NTSB. Data on the number of hours 
"other" instructors spent preparing to teach is not collected by NTSB. 

[End of figure] 

Finally, NTSB classified its lease for the academy as an operating 
lease rather than a capital lease. As a result, NTSB has been 
noncompliant with the Anti-Deficiency Act because it did not obtain 
budget authority for the net present value of the entire 20-year lease 
obligation at the time the lease agreement was signed in 2001. NTSB 
realized the error in 2003 and reported its noncompliance to Congress 
and the President. NTSB has proposed in the President's fiscal year 
2007 budget to remedy this antideficiency act violation by inserting an 
amendment in their fiscal year 2007 appropriation that would allow NTSB 
to fund this obligation from their salaries and expense account through 
fiscal year 2020. 

Conclusions: 

Mr. Chairman, we have developed several conclusions from our analysis 
of NTSB to date. To the credit of the current leadership at NTSB, much 
of the agency's progress toward following leading practices is due to 
recent management initiatives. The performance management plan, draft 
staffing plan, and implementation of controls over financial 
transactions are all positive steps. NTSB's progress in these areas 
will likely remain incomplete without additional actions, however. For 
example, without a more comprehensive strategic plan than it currently 
has, NTSB cannot align staffing, training, or other human resource 
management to its strategic goals or align its organizational structure 
and layers of management with the plan. NTSB will also likely miss 
opportunities to strengthen the management of the agency until it 
develops a strategic training plan for its employees, implements a full 
cost-accounting system, and improves communications within the agency. 

We have also concluded that, despite the many safety recommendations 
NTSB has made and seen implemented over the years of its existence, 
inefficiencies have resulted from the process that the agency uses to 
close out safety recommendations. In particular, the absence of a 
computerized documentation system and the sequential reviews that NTSB 
currently requires slow the process and prevent expedient delivery of 
information about recommendation status to affected agencies. Finally, 
in terms of its academy, NTSB is missing opportunities to increase the 
value of this asset. Without a comprehensive marketing plan, NTSB will 
likely be unable to efficiently attract users who would help pay the 
ongoing costs of the facility. 

Recommendations for Executive Action: 

To improve the efficiency of agency operations, we are making eight 
recommendations to the Chairman of the National Transportation Safety 
Board based on our completed work to date. To improve agency 
performance in the key functional management areas of strategic 
planning, human capital planning, financial management, and 
communications, we recommend that the Chairman implement the following 
three recommendations: 

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

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

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

To enhance the efficiency of the report development and recommendation 
close-out processes, we recommend that the Chairman take the following 
two actions: 

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

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

To enhance the utilization of the academy and improve the ability to 
generate revenues that will cover academy costs, we recommend that the 
Chairman take the following three actions: 

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

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

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

Agency Comments: 

We obtained comments on a draft of this testimony from NTSB. NTSB's 
Managing Director concurred with our recommendations and provided 
clarifying comments and technical corrections, which we incorporated as 
appropriate. In addition, NTSB commented that the draft did not 
sufficiently distinguish improvements that have been made over the past 
year. We revised the testimony to more clearly distinguish those 
actions. 

Scope and Methodology: 

To determine the extent to which NTSB is following leading practices in 
selected management areas, we reviewed past GAO work on leading 
management practices in the areas of strategic planning, performance 
management, human capital management, financial management, and 
communications. We interviewed NSTB board members, senior officials, 
managers, investigators, and writer editors regarding their experience 
with those practices at NTSB, and their perceptions of the 
effectiveness of those practices. We also determined NTSB's response to 
recommendations made by the DOTIG. We reviewed NTSB documents, 
including its strategic, staffing, and performance management plans; 
management advisory e-mail; and information regarding the current 
staffing levels; and employees' training plans for 2006. 

To determine the extent to which NTSB is developing accident 
investigation reports and closing safety recommendations in an 
efficient manner, we interviewed NTSB investigators, writer editors, 
managers, and senior officials regarding the investigative process and 
their role in it. We randomly selected 15 of the 210 investigators and 
8 writer editors evenly across the 4 modal offices. The views represent 
the particular individuals and are not representative of all NTSB 
investigators and writer editors. We reviewed policy guidance on the 
investigative process and the level of current and past investigation 
activity. We examined data on recommendations acceptance rates and 
close-out status from NTSB's recommendation database, and we determined 
that the data were sufficiently reliable for the objectives of this 
review. Additionally, we reviewed studies done by the Rand Corporation 
and Booz Allen Hamilton that examined NTSB's investigation process and 
determined the extent to which the agency had implemented their 
recommendations. 

To determine the extent to which NTSB is generating sufficient revenues 
to cover costs at its academy, we reviewed financial data on NTSB's 
academy, including the revenues and expenses for fiscal years 2004 and 
2005. We reviewed the course curriculum of the academy, and compared it 
with classes offered by DOT's Transportation Safety Institute, Embry 
Riddle, the University of Southern California, and the Southern 
California Safety Institute. We examined data on the student makeup of 
academy classes and analyzed data on the preparatory and teaching time 
used by NTSB investigators who taught at the academy. We interviewed 
NTSB investigators, writer editors, and managers and senior officials 
at DOT's modal administrations regarding their current and planned use 
of the academy. Finally, we examined the lease for the academy to 
determine how NTSB may utilize the space. 

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

Contacts and Acknowledgments: 

For further information on this testimony, please contact Dr. Gerald 
Dillingham at (202) 512-2834 or by e-mail at dillinghamg@gao.gov. 
Individuals making key contributions to this testimony include Teresa 
Spisak, Colin Fallon, Eric Fielding, Tom Keightley, Maren McAvoy, Josh 
Ormond, and Jena Whitley. 

FOOTNOTES 

[1] Department of Transportation Act, P.L. 89-670, Oct. 15, 1966. 

[2] Independent Safety Board Act, P.L. 93-633, Title III, 1974. 

[3] NTSB conducts safety studies as a result of identifying safety 
concerns rather than as a result of specific accidents. 

[4] Not more than three members may be appointed from the same 
political party. At least three members are appointed on the basis of 
technical qualification, professional standing, and demonstrated 
knowledge in accident reconstruction, safety engineering, human 
factors, transportation safety, or transportation regulation. 

[5] 49 U.S.C Sec. 1132(c). 

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

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

[8] GAO, A Model of Strategic Human Capital Management, GAO-02-373SP 
(Washington, D.C.: March. 15, 2002) and GAO, Human Capital: Key 
Principles for Effective Strategic Workforce Planning, GAO-04-39 
(Washington, D.C.: December 11, 2003). 

[9] GAO, Executive Agency Management Diagnostic Survey (draft). 

[10] Each investigative team initially consists of at least one 
investigator-in-charge and other technical support investigator 
positions based on the complexity of the accident. 

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

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

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

[14] DOTIG, Audit of the Purchase Card Program, FI-2005-072 
(Washington, D.C.: Aug. 23, 2005) and Report on Financial Management 
Practices and Internal Controls, FI-2003-004 (Washington, D.C.: Dec. 
11, 2002). 

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

[16] RAND Institute for Civil Justice, 2000. 

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

[18] We randomly selected 15 investigators and 8 writer editors evenly 
across the 4 modal offices and interviewed them to obtain their views 
on NTSB's processes. The views represent the particular individuals and 
are not representative of all NTSB investigators and writer editors. 

[19] The writer editors held a conference in February 2004. 

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

[21] In fiscal years 1999 and 2002, Booz Allen Hamilton found that the 
average time to complete a major investigation was 1.8 years; in fiscal 
years 2001 and 2003, the average time was 1.9 years; in fiscal year 
2000 the average was 2.4, mainly due to several lengthy aviation 
investigations that took over 4 years to complete. 

[22] Booz Allen Hamilton, however, found that the logic and rationale 
for changes made during the review process were not transparent. 

[23] 49 USC Sec. 1135(d). NTSB pointed out that for those 
recommendations on the Most Wanted List, it specifically updates the 
list each November to ensure sufficient time for DOT to file its annual 
report to Congress. 

[24] Senate Report 109-109 accompanying P.L. 109-115, the 
Transportation, Treasury, the Judiciary, Housing and Urban Development, 
and Related Agencies Appropriations Act of 2006. 

[25] The revenue deficient for the 14 sessions totaled $54,279, and the 
revenue surplus for the two years totaled $307,203. 

[26] If the tuition fee is set by dividing the costs attributable to a 
course by the projected class size, the fee may not be competitive with 
fees charged by other institutions offering similar courses. In that 
case, the projected class size might not be attainable without lowering 
the tuition to a competitive level, with the result that fee revenues 
collected might not cover the attributable costs. 

[27] NTSB has a memorandum of understanding with GAO for the two 
agencies to reciprocate in providing continuity of operations. There is 
no annual fee associated with this agreement, only cost reimbursement 
after the first 14 days of providing space. 

[28] The academy facility contains five classrooms, a large warehouse 
that houses aircraft and other wreckage, eating and lounge areas, and 
office space for five employees who constitute NTSB's Washington field 
office. 

[29] We excluded federal holidays and the last week in December from 
our analysis. In some cases, courses used multiple classrooms. We 
lacked specific information on which courses used multiple classrooms. 
To account for that situation, we rounded up the percentage of space 
utilized. The use of multiple classrooms does not affect the 
information on the lack of using any classrooms for 21 weeks. 

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

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

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

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

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

GAO's Mission: 

The Government Accountability Office, the audit, evaluation and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the performance 
and accountability of the federal government for the American people. 
GAO examines the use of public funds; evaluates federal programs and 
policies; and provides analyses, recommendations, and other assistance 
to help Congress make informed oversight, policy, and funding 
decisions. GAO's commitment to good government is reflected in its core 
values of accountability, integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's Web site (www.gao.gov). Each weekday, GAO posts 
newly released reports, testimony, and correspondence on its Web site. 
To have GAO e-mail you a list of newly posted products every afternoon, 
go to www.gao.gov and select "Subscribe to Updates." 

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. Government Accountability Office 441 G Street NW, Room LM 
Washington, D.C. 20548: 

To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202) 
512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov 
Automated answering system: (800) 424-5454 or (202) 512-7470: 

Congressional Relations: 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S. 
Government Accountability Office, 441 G Street NW, Room 7125 
Washington, D.C. 20548: 

Public Affairs: 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800 
U.S. Government Accountability Office, 441 G Street NW, Room 7149 
Washington, D.C. 20548: