National Transportation Safety Board (NTSB)
Liberty University
AVIA 409 - Safety Management Systems
Professor: Andrew Walton
2022
National Transportation Safety Board (NTSB)
The NTSB is an independent Federal agency charged by Congress with investigating every civil
aviation accident in the United States and significant accidents in other modes of transportation
railroad, highway, marine, and pipeline. The NTSB determines the probable cause of the accidents and
issues safety recommendations aimed at preventing future accidents.
The NTSB is also responsible for maintaining the U.S. database of civil aviation accidents, and
it conducts special studies of transportation safety issues of national significance. The NTSB
performs an administrative review function for certificate actions taken by the FAA under 49
USC 44709 or civil penalty actions initiated by the FAA against persons acting as pilots,
mechanics, repairmen, or flight engineers.
The NTSB is not part of the DOT, nor is it affiliated with any of its modal administrations (such as
the FAA). The Board derives its authority from 49 USC Chapter . Title 49 of the USC provides the NTSB
and its investigators with the authority to carry out investigations, including control of wreckage and
accident sites; entry into and inspection of any relevant facility; conduct of any relevant testing or
examination; and interview of witnesses.24F The NTSB is the government agency charged with the
responsibility for assuring compliance with U.S. obligations under ICAO Annex 13, Aircraft Accident and
Incident Investigation.
NTSB Office of Aviation Safety
The Office of Aviation Safety within NTSB is responsible for conducting the aviation accident
investigation and reporting activities described above. It investigates and reports on all
accidents involving U.S. air carrier, commuter, air taxi, and general aviation aircraft, as well as
certain accidents involving public aircraft operations. It also investigates accidents involving both
civilian and military aircraft. Additionally, the NTSB Office of Aviation Safety conducts
investigations of safety issues that extend beyond a single accident to examine specific aviation
safety problems from a broader perspective.
In conjunction with other offices within the NTSB, the Office of Aviation Safety also works to
formulate recommendations to prevent the recurrence of similar accidents and incidents, and to
otherwise improve aviation safety. The Office of Aviation Safety includes a number of regional
offices spread throughout the U.S. to ensure that NTSB personnel are within closer proximity to
potential accident sites.
The National Transportation Safety Board (NTSB) is an independent U.S. government
investigative agency responsible for civil transportation accident investigation. In this role, the NTSB
investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and
marine accidents, pipeline incidents, bridge failures, and railroad accidents.[2] The NTSB is also in charge
of investigating cases of hazardous materials releases that occur during transportation. The agency is
based in Washington, D.C. It has four regional offices, located in Anchorage, Alaska; Denver, Colorado;
Ashburn, Virginia; and Seattle, Washington.[3] The agency also operates a national training center at its
Ashburn facility.[4]
History
NTSB headquarters
The origin of the NTSB was in the Air Commerce Act of 1926, which assigned the United States
Department of Commerce responsibility for investigating domestic aviation accidents. Before the NTSB,
the Federal Aviation Administration's (FAA; at the time the CAA) independence was questioned as it was
investigating itself and would be biased to find external faults, coalescing with the 1931 crash killing
Notre Dame coach Knute Rockne. The USA's first "independent" Air Safety Board was established in
1938: it lasted only fourteen months. In 1940, this authority was transferred to the Civil Aeronautics
Board's newly formed Bureau of Aviation Safety.
In 1967, Congress created a separate cabinet-level Department of Transportation, which among
other things established the Federal Aviation Administration as an agency under the DOT.[9] At the same
time, the NTSB was established as an independent agency which absorbed the Bureau of Aviation
Safety's responsibilities. However, from 1967 to 1975, the NTSB reported to the DOT for administrative
purposes, while conducting investigations into the Federal Aviation Administration, also a DOT agency.
To avoid any conflict, Congress passed the Independent Safety Board Act, and on April 1, 1975,
the NTSB became a fully independent agency. As of 2015, the NTSB has investigated over 140,000
aviation incidents and several thousand surface transportation incidents.
Organization
Formally, the "National Transportation Safety Board" refers to a five-manager investigative board
whose five members are nominated by the President and confirmed by the Senate for five-year terms.
No more than three of the five members may be from the same political party. One of the five board
members is nominated as the Chairman by the President and then approved by the Senate for a fixed 2-
year term; another is designated as vice-chairman and becomes acting chairman when there is no
formal chairman. This board is authorized by Congress under Chapter 11, Title 49 of the United States
Code to investigate civil aviation, highway, marine, pipeline, and railroad accidents and incidents. This
five-member board is authorized to establish and manage separate sub-offices for highway, marine,
aviation, railroad, pipeline, and hazardous materials investigations.
Since its creation, the NTSB's primary mission has been "to determine the probable cause of
transportation accidents and incidents and to formulate safety recommendations to improve
transportation safety (in the USA)". Based on the results of investigations within its jurisdiction, the
NTSB issues formal safety recommendations to agencies and institutions with the power to implement
those recommendations. The NTSB considers safety recommendations to be its primary tool for
preventing future civil transportation accidents. However, the NTSB does not have the authority to
enforce its safety recommendations.
Accident and incident investigations
The NTSB is the lead agency in the investigation of a civil transportation accident or incident
within its sphere. An investigation of a major accident within the United States typically starts with the
creation of a "go team," composed of specialists in fields relating to the incident who are rapidly
deployed to the incident location. The "go team" can have as few as three people or as many as a dozen,
depending on the nature of the incident. Following the investigation, the agency may then choose to
hold public hearings on the issue. Ultimately, it will publish a final report which may include safety
recommendations based on its findings. The NTSB has no legal authority to implement or impose its
recommendations. Its recommendations are often implemented by regulators at the federal or state
level, or individual transportation companies.
Jurisdiction over investigations
Aviation
The NTSB has primary authority to investigate every civil aviation accident in the United States;
the agency is also authorized to conduct investigations involving both civilian and military aircraft "with
the participation of appropriate military authorities". For certain accidents, due to resource limitations,
the Board will ask the FAA to collect the factual information at the scene of the accident; the NTSB bases
its report on that information.
Surface Transportation
The NTSB has the authority to investigate all highway accidents and incidents, including incidents
at railway grade crossings, "in cooperation with a State”. The NTSB has primary jurisdiction over railway
accidents and incidents which result in death or significant property damage, or which involve a
passenger train.
Marine
For marine investigations, jurisdiction into investigations is divided between the NTSB and the U.S.
Coast Guard. The division of investigative jurisdiction and responsibilities is prescribed in a detailed
Memorandum of Understanding between the two agencies.
Pipeline
The NTSB has primary jurisdiction over pipeline incidents (often the result of third-party
excavation damage) which involve "a fatality, substantial property damage, or significant injury to the
environment".
Assistance to criminal investigations
The NTSB has primary jurisdiction over civil transportation investigations, but not criminal
investigations. If the Attorney General declares the case to be linked to a criminal act, the NTSB must
relinquish control of the investigation to the Federal Bureau of Investigation. The NTSB may still provide
technical support to the FBI in such investigations. In two high-profile examples, the NTSB sent aviation
accident investigators with knowledge of aircraft structures and flight recorders to assist the FBI's
criminal investigation into the murder-suicide of Pacific Southwest Airlines Flight 1771 in 1987, and the
September 11, 2001, attacks fourteen years later.
Assistance to other domestic agencies
In addition to assisting the Department of Justice in criminal investigations, the NTSB has also
assisted the National Aeronautics and Space Administration (NASA) in its investigations of both the
Challenger and the Columbia Space Shuttle disasters. The NTSB also provides assistance on request to
the U.S. military in its investigation of military incidents within the realm of the NTSB's expertise, such as
the crash of an Air Force transport plane in former Yugoslavia that took the lives of more than 30
Americans, including Commerce Secretary Ron Brown.
Assistance to foreign governments
The NTSB may assist in incident or accident investigations occurring outside the United States
under certain circumstances. These may include accidents or incidents involving American-registered or
American-owned civil aircraft or aircraft with U.S. manufactured components in foreign air space.
Officially, NTSB employees are prohibited from releasing information about "another country's
investigation".
Use of the "party system"
In order to conduct its investigations, the NTSB operates under the "party system", which utilizes
the support and participation of industry and labor representatives with expertise or technical
knowledge specifically useful to its investigation. These individuals or organizations may be invited by
the NTSB to become parties to the investigation, and participate under the supervision of the NTSB. The
NTSB has discretion over which organizations it allows to participate. Only individuals with relevant
technical expertise are allowed to represent an organization in an investigation, and attorneys and
insurance investigators are prohibited by law from participating.
The NTSB considers the party system crucial to the investigative process, as it provides the NTSB
with access to individuals with specialized expertise or knowledge relevant to a particular investigation.
However, use of the party system is not without controversy. The NTSB invited Boeing to participate as a
party to the investigation of the crash of TWA Flight 800, a Boeing 747, in 1996. While the NTSB relied
on Boeing's sharing of expertise, it was later determined that Boeing had withheld a study of military
versions of the 747 that investigated flammable vapor combustion in the center fuel tank. Boeing had
told the NTSB that it had no studies proving or disproving the vapor combustion theory. In response to
political pressure after the Boeing incident, the NTSB commissioned the nonprofit Rand Corporation to
conduct an independent study of the NTSB's aircraft investigation process.
In 2000, Rand published its report, which concluded that the party system is "a key component of
the NTSB investigative process" and that participant parties "are uniquely able to provide essential
information about aircraft design and manufacture, airline operations, or functioning of [the National
Airspace System] that simply cannot be obtained elsewhere". However, Rand also found conflicts of
interest inherent in the party system, "may, in some instances, threaten the integrity of the NTSB
investigative process". The Rand study recommended that the NTSB reduce its reliance on party
representatives and make greater use of independent investigators, including from NASA, the
Department of Defense, government research laboratories, and universities. As of 2014, the NTSB has
not adopted these recommendations and instead continues to rely on the party system.
