The National Transportation Safety Board (NTSB) is an independent federal agency responsible for investigating civilian aviation accidents, along with accidents involving highways, ships, pipelines, and railroads. When requested, the NTSB will assist the military with accident investigation, and it is charged with investigating cases of hazardous waste releases that occur during transportation. Since its inception in 1967, the NTSB has investigated more than 124,000 aviation accidents and over 10,000 surface transportation accidents. On call 24 hours a day, 365 days a year, NTSB investigators travel throughout the country, and sometimes overseas, to investigate significant accidents and develop factual records and safety recommendations. Sometimes, however, the board’s safety warnings are not heeded, as has been the case over the danger of ice forming on aircraft wings. For the past decade, the NTSB has repeatedly called for new regulations to address this danger, only to watch the Federal Aviation Administration (which regulates air travel) ignore their warnings. The crash of a Continental Airlines plane in upstate New York in February 2009 once again raised the issue of whether airlines and the FAA are adequately addressing this risk. The NTSB was ranked the thirteenth best small agency to work in for the federal government in 2011.

As early as 1926, Congress required the investigation of civil aviation crashes under the Air Commerce Act. Over the next three decades, lawmakers created a maze of regulatory agencies, including the Civil Aeronautics Authority and the Federal Aviation Administration (FAA). The Federal Aviation Act of 1958 gave duties for investigating accidents to the Civil Aeronautics Board (CAB), intending for the board to study aircraft and the actions of their pilots in the hopes of preventing future disasters.

As the airline industry grew, Congress reorganized the federal government’s regulatory scheme. With passage of the Department of Transportation Act of 1966, lawmakers created the National Transportation Safety Board (NTSB) within the Department of Transportation and gave it the responsibilities formerly held by the CAB.

However, the NTSB often ended up conducting investigations of the FAA. So, in an attempt to avoid conflicts between agencies, Congress made the NTSB an independent board by passing the Independent Safety Board Act of 1974, which gave the NTSB sole responsibility for investigating airline crashes.

Since its inception in 1967, the NTSB has investigated more than 132,000 aviation accidents and over 10,000 surface transportation accidents. It has issued more than 13,000 recommendations in all transportation modes to more than 2,500 recipients.

History of the National Transportation Safety Board (NTSB)

The National Transportation Safety Board (NTSB) is the primary federal agency for conducting investigations of all civil aviation accidents in the United States as well as major accidents involving highways, shipping, pipelines, hazardous material, and railroads. The NTSB has no regulatory or enforcement power, and its analysis of factual information and determination of probable cause cannot be entered as evidence in a court of law.

The NTSB is led by five members, each nominated by the President and confirmed by the Senate to serve five-year terms. A member is designated by the President as chairman and another as vice chairman for two-year terms. The chairmanship requires separate Senate confirmation.

The board investigates about 2,000 aviation accidents and incidents a year, and about 500 accidents involving rail, highway, marine, and pipeline. With only some 400 employees, the NTSB relies on assistance from other organizations or companies to carry out its investigations. Other than the FAA, which by law is automatically designated a party, the NTSB has complete discretion over which organizations it designates as parties to an investigation. In cases of suspected criminal activity, other agencies may participate in the investigation. The NTSB does not investigate criminal activity, which usually falls to the FBI.

At the core of NTSB investigations is the “Go Team.” The team can number from three or four to more than a dozen specialists from the board’s headquarters staff in Washington D.C., who are assigned on a rotational basis to respond as quickly as possible to the scene of an accident. Go Teams travel by commercial airliner or government aircraft depending on circumstances and availability. They also routinely handle investigations of certain rail, highway, marine, and pipeline accidents. Go Team members must be reachable 24 hours a day by telephone at the office or at home, or by pager.

The Go Team’s lead member is the investigator-in-charge (IIC), a senior investigator with years of NTSB and industry experience. Each investigator is a specialist responsible for a clearly defined portion of the accident investigation. In aviation, these specialties and their responsibilities include:

• Operations: The history of the accident flight and crewmembers’ duties for as many days prior to the crash as appears relevant
• Structures: Documentation of the airframe wreckage and the accident scene, including calculation of impact angles to help determine the plane’s pre-impact course and attitude
• Power plants: Examination of engines (and propellers) and engine accessories
• Systems: Study of components of the plane’s hydraulic, electrical, pneumatic and associated systems, together with instruments and elements of the flight control system
• Air Traffic Control: Reconstruction of the air traffic services given the plane, including acquisition of ATC radar data and transcripts of controller-pilot radio transmissions
• Weather: Gathering of all pertinent weather data from the National Weather Service, and sometimes from local TV stations, for a broad area around the accident scene
• Human Performance: Study of crew performance and all before-the-accident factors that might be involved in human error, including fatigue, medication, alcohol. Drugs, medical histories, training, workload, equipment design and work environment
• Survival Factors: Documentation of impact forces and injuries, evacuation, community emergency planning and all crash-fire-rescue efforts.

The NTSB is required to address safety deficiencies immediately, even before completion of an investigation. These are often issued as safety alerts.

The board may hold a public hearing as part of a major transportation accident investigation. The purpose of the hearing is twofold; first, to gather sworn testimony from subpoenaed witnesses on issues identified by the board during the course of the investigation; and, second, to allow the public to observe the progress of the investigation. Hearings are usually held within six months of an accident, but may be delayed for complex investigations.

After months of investigation, testing and analysis, the board’s staff prepares a draft final report. Parties invited to assist in an investigation do not participate in the analysis and writing phase of NTSB reports, though they are invited to submit their proposed findings of cause and proposed safety recommendations, which are made part of the public docket. The board then deliberates over the final report in a public meeting in Washington D.C. Non-NTSB personnel, including parties and family members, cannot interact with the board during that meeting. Final reports adopted by the board are then made available on the NTSB web site under Accident Reports. The board’s Aviation Accident Database is also accessible to the public.

The National Transportation Safety Board: Background and Issues for Reauthorization

and Congressional Oversight (by Bartholomew Elias, Congressional Research Service)

Major Investigations Manual (NTSB) (pdf)

Major Investigations Manual - Appendices (NTSB) (pdf)

From the NTSB Web Site:

Accident Reports

Contact NTSB

Current Investigations

Databases

Disaster Assistance

Events

FAQs

Most Wanted List

Office Locations

Press Releases

Report an Accident

Safety Alerts

Speeches and Testimony

Strategic Plans and Reports

According to USASpending, the National Transportation Safety Board (NTSB) spent $69.6  million from 2002-2011 on 2,101 transactions with companies and other organizations. Primary services included office space ($10 million), operation of electronic and communications facilities ($6.3 million), ADP software ($5.294 million), technical assistance ($5.2 million), and program management ($3.3 million).

The top five recipients of NTSB contracts were:

1. Potomac Creek Associates L.L.C.                          $7,200,182

2. Northrop Grumman Corporation                           $6,376,860

3. InfoReliance Corporation                                       $4,381,547

4. Dell Inc.                                                                  $2,980,506

5. The George Washington University                       $2,893,782 

Performance and Accountability Report FY 2010 & 2011 (pdf)

Warnings about Air Traffic Controllers Falling Asleep

The National Transportation Safety Board (NTSB) found itself in the middle of an uproar in 2011 after it was learned air traffic controllers were caught sleeping on the job. Most of the heated was felt by the agency that oversees the controllers, the Federal Aviation Administration, which fired the head of the U.S. air traffic system. The FAA also doubled the number of controllers at more than two-dozen airports and ordered a review of the entire air-traffic system after four accounts of controllers sleeping on the job surfaced.

The NTSB, it turned out, had warned the FAA as early as 2006 that controllers were working too many hours and not getting enough rest. But the FAA took no action until the problem became a national headline.

The NTSB continued to push for updated aviation-fatigue rules, including a provision that would allow controllers to take authorized naps during their breaks.

The issue lasted several weeks in the news, and was extended after a plane carrying first lady Michelle Obama had a close call with another aircraft. In that incident, a controller mistakenly told the pilot of Obama’s plane that a military cargo jet was four miles away, when actually it was three miles. And the controller made things worst by instructing the pilot to change direction, bringing the plane even closer to the other aircraft.

FAA Tries to Quell Sleeping Controller Controversy (by Joan Lowy, Associated Press)

Controller Fatigue Divides Agencies, Union (by Andy Pasztor, Wall Street Journal)

FAA Knew Controllers Nap, Ignored Fatigue Issue (by Charles Czeisler, CNN)

US First Lady Michelle Obama's Jet Got Wrong Info on Other Plane (Times of India)

Safety Recommendations Go Unheeded

For years if not decades, the NTSB has made recommendations to the Federal Aviation Administration on ways to make air travel safer. In many instances, the FAA has failed to adopt the NTSB’s proposals.

The oldest known recommendation was put forth during the Clinton administration. Then, the NTSB urged the FAA to require pilots to routinely train on ways to avoid a midair collision once the onboard Traffic Collision and Alerting System goes off in the cockpit.

Beginning in 2005, the NTSB began emphasizing the importance of maintaining professionalism among pilots and air traffic controllers. As of 2011, 19 recommendations to the FAA had not been resolved to the safety board’s satisfaction. This despite numerous recent examples of pilots not behaving properly, such as having a conversation with an open mike in the cockpit, overflying airports and simply not paying attention to their jobs.

Another important changed pushed by the NTSB has involved young children on board planes. The FAA has continued to allow passengers 2 years old and younger to not have a seat of their own and instead sit on a parent’s lap. The board feels this needs to change, citing examples of children getting seriously injured or killed when not restrained in their own seat.

Transportation Safety Board: Hold Pilots Accountable To Raise Professionalism (by Ashley Halsey III, Washington Post)

Babies on Planes: Debate over Safety Renewed (by Harriet Baskas, MSNBC)

17 Years of FAA Delay on NTSB Air Safety Recommendations (by Barbara Hollingsworth, Washington Examiner)

Fact Sheet – FAA & NTSB’s “Most Wanted” Recommendations (Federal Aviation Administration)

NTSB Criticizes FAA for Air Safety Deficiencies

The NTSB faulted the FAA for failing to notice problems with a charter airline in the June 4, 2007, plane crash that occurred in Lake Michigan. The crash killed all six aboard the flight, including four members of a University of Michigan lung transplant team. NTSB investigators ruled that the fatal crash might have been avoided if the federal inspectors of the FAA had noticed the charter airline allowed a convicted drug runner to conduct critical safety checks. The NTSB alleged that the two pilots, one of whom was the one who had performed the inspection, were to blame for the crash. The airplane had an emergency shortly after takeoff, but the pilots could have returned the plane to a safe landing. The fact that an inspection had been performed by a former drug runner, in addition to the pilot’s unfamiliarity with the jet, had gone unnoticed by the FAA. The FAA failed to detect and correct deficiencies of the charter airline, Marlin Air. The FAA said they would look at the report for lessons.

NTSB Faults Pilots, FAA in 2007 Charter Plane Crash (by Alan Levin, USA Today)

NTSB Warnings about Ice on Planes Ignored

For more than a decade, the NTSB has called for tougher regulations to protect planes flying in the kind of icy conditions that possibly downed a Continental Connection flight in New York in February 2009, but again and again, the FAA has ignored these recommendations. This has proved frustrating for the NTSB, which first recommended improved icing regulations in their “Most Wanted Transportation Safety Improvements” in 1997 and then added to those recommendations several times over the years. “The pace of the FAA’s activities in response to these recommendations remains unacceptably slow, despite recent encouraging action,” Steven Chealander, the safety board member who investigated the crash of Continental Flight 3407, told a Senate committee in April 2008. The FAA conceded in April 2007 that icing poses “an insidious hazard to aircraft.” “It takes a little while to get this stuff going,” said Jim Peters, an FAA spokesman. “Rulemaking takes a period of time.” The FAA formed an ice protection working group within its rulemaking advisory committee and, in June 2010, proposed new regulations that would require aircraft and engine manufacturers to demonstrate safe operations in a range of icing conditions. The FAA has fined carriers for violating de-icing program maintenance because FAA regulations state that carriers are responsible for overseeing contractors’ maintenance.

Safety Aides Chide FAA for Ignoring Warnings on Ice (by Robert J. McCarthy and Jerry Zremski, BuffaloNews.com)

Fire Fighting Planes Grounded after NTSB Report

The NTSB raised concerns in Montana and throughout the West in 2004 following the release of a report about the safety of aircraft used to fight forest fires. As the summer fire season began, the Forest Service and Interior Department terminated contracts for 33 large air tankers provided by eight private companies. The decision came in response to an investigation by the NTSB into three air tanker crashes in which one or both wings fell off the planes during flight. The NTSB blamed inadequate maintenance and inspection procedures for the accidents. The report, and subsequent contract terminations, resulted in protests from residents in Missoula, Montana, who started wearing green ribbons to raise awareness of the plight of Neptune Aviation, a contractor that owned and operated large air tankers used in fighting wildfires. The decision to drop the tankers from the firefighting fleet prompted congressional hearings and letters of protest from Western governors.

Controversy Flies around Grounded Firefighting Tankers (by Denise Kersten, GovernmentExecutive.com)

Mark V. Rosenker

A native of Virginia, Mark V. Rosenker was sworn in as the 11th chairman of the National Transportation Safety Board on August 11, 2006. His two-year term as chairman expired in August 2008, and he then served as acting chairman.

Rosenker spent the majority of his professional career (37 years) in the U.S. Air Force. A retired major general in the Air Force Reserve, Rosenker entered the Air Force in 1969 through the University of Maryland ROTC program. He is a graduate of the Air Command and Staff College and the Air War College.

In addition to his Air Force career, Rosenker served 23 years as vice president of public affairs for the Electronic Industries Alliance. He then became managing director of the Washington D.C. office for the United Network for Organ Sharing (UNOS), overseeing the development, implementation and management of a national public information program dealing with all facets of organ transplantation in the U.S. Beginning January 20, 2001, Rosenker served as deputy assistant to the President and director of the White House Military Office. In this capacity, he had responsibility for policies, personnel and plans that involve Department of Defense assets in direct support of the President.

Rosenker’s professional experience also includes service in the federal government at the Department of Interior, the Federal Trade Commission and the Commodity Futures Trading Commission. In 1990, he was appointed by President Bush a member of the American Battle Monuments Commission (ABMC).

He was first appointed to the NTSB in 2003, and is currently serving his second five-year term, which expires December 31, 2010. While serving on the board, Rosenker was the board member on scene for the NTSB’s investigations into the April 2004 derailment of Amtrak’s City of New Orleans near Flora, Mississippi; the November 2004 crash of a charter jet aircraft in Houston, Texas (the plane was on its way to pick up former President George H.W. Bush for a flight to Latin America); the September 2005 derailment of a Metra commuter train in Chicago; the October 2005 capsizing of the passenger vessel Ethan Allen in Lake George, New York, which claimed 20 lives; the November 2005 grade crossing collision involving a Metra commuter train in Chicago; the December 2005 crash of a seaplane in Miami, Florida, that killed all 20 persons aboard; the November 2006 accident in Alexandria, Virginia, where two track inspectors were killed when struck by a transit train; the January 2007 derailment of a CSX freight train in Shepherdsville, Kentucky, that resulted in a hazardous materials spill and fire; the August 2007 collapse of the I-35W bridge in Minneapolis, Minnesota, that killed 13 motorists who were crossing the bridge at the time of the collapse; the June 2008 midair collision of two emergency medical helicopters in Flagstaff, Arizona; and the investigation of the crash of the small aircraft piloted by adventurer Steve Fossett, after the wreckage was found in October 2008, more than a year after the aircraft was reported missing. He also was part of the NTSB's Go Team for the June 2003 capsizing of the charter fishing vessel Taki-Tooo, near Garibaldi, Oregon, which took the lives of 11 of the 19 people aboard.

In March 2008, Rosenker chaired the NTSB’s public hearing into the accident involving a cargo ship that struck the fendering system of the San Francisco-Oakland Bay Bridge.