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See original posting at Rand web site
December 9, 1999
Contact: Jess Cook
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P. O. Box 2138
Santa Monica, CA 90407-2138
1333 H Street, NW
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STUDY OF NTSB AVIATION ACCIDENT INVESTIGATIONS SUGGESTS MAJOR CHANGES IN HOW PROBES ARE CONDUCTED
AGENCY NEEDS NEW RESOURCES TO INVESTIGATE COMPLEX ACCIDENTS
WASHINGTON, D.C. December 9 - With its staff and facilities already "stretched to the limit," the National Transportation Safety Board must acquire additional resources, modernize its investigative procedures, and reform some of its key management practices on an urgent basis if it is to ensure its future independence and integrity. The agency also needs to augment the "party process,"--the traditional practice of allowing interested stakeholders such as airlines, aircraft manufacturers and the Federal Aviation Administration to join in crash probes--by tapping academia, federal agencies such as NASA and the Defense Department, and other sources of independent, analytical expertise.
ROLE OF INTERESTED PARTIES RAISES CONCERNS ABOUT CONFLICT OF INTEREST
These are the key recommendations in a RAND study commissioned by NTSB Chairman Jim Hall last year. The study provides the most comprehensive examination of NTSB operations in the agency's 30-year history. The executive summary is being released by the two organizations today. A longer, technical volume will be available early next year.
To carry out the study, RAND's Institute for Civil Justice assembled a multidisciplinary research team. Led by Cynthia C. Lebow, a lawyer, the team included Liam P. Sarsfield, a mechanical engineer and public policy specialist, William L. Stanley, an aerospace engineer, Emile Ettedgui, a physicist, and Garth Henning, an aerospace engineer. As part of the broad-based effort, the researchers held more than 200 confidential interviews with stakeholders from all segments of the aviation community and conducted accident case studies, site visits and a comprehensive review of aviation accident litigation.
In reacting to the study, NTSB Chairman Hall expressed appreciation for RAND's "candid, independent, and honest review. We have already begun the process of change and improvement they recommended to ensure that the Board continues to serve the American people in the best way possible," Hall said.
The study notes that the agency plays a central role in aviation safety and still enjoys the reputation of being the most important independent safety investigative authority in the world. It adds, however, that recent accidents, such as TWA Flight 800 and USAir Flight 427, have "challenged the ability of the technical staff to unravel the kinds of complex failures that led to such horrific tragedies." NTSB investigators must be able to "ask the right questions" and know whether or not they are receiving the right answers. The integrity and independence of the safety board could be threatened if the skills of NTSB investigators are allowed to erode or if the information received from outside parties is unreliable.
The RAND report identifies several tasks for immediate action. These include:
RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.
- Revamp Investigative Procedures: The NTSB's investigative procedures and techniques are not keeping pace with modern aircraft design and operation. The agency should modernize its investigative methods to reflect the complexity of the accidents it is asked to solve. Also, it should take a more proactive stance in investigating nonfatal incidents and breaches of security, both in the air and on the ground.
- Expand NTSB Resources: The NTSB's 400-member staff is overworked and not adequately equipped. Sheer dedication and professionalism have allowed the safety board to maintain its traditional high standard of performance. Additional resources are imperative, including more personnel and improved facilities for testing and staff training.
- Augment the Party System: The party system is a key component of the NTSB investigative process. However, stakeholders likely to be chosen as parties to assist in an NTSB investigation are also likely to be named defendants in related high-stakes civil litigation. To avoid the potential for party conflict of interest, the agency should consider methods for augmenting the party process that provide access to independent analytical and engineering resources during the investigation of high-profile accidents. Such methods include the development of new relationships with other federal agencies and laboratories (NASA, DoD), universities, and independent experts.
- Expand the Statement of Probable Cause: The statement of probable cause--the most eagerly awaited and controversial aspect of the NTSB's final accident report--should be retained but expanded. In addition to clearly stating the principal event that led to the accident, the statement should also include all other causal factors listed in rank order. The result would be a more complete statement of causation with greater utility to the goal of aviation safety.
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