Thursday, December 9, 1999, 11:23 a.m. Pacific 

Study finds NTSB teetering 'near the breaking point' 

     by Chuck Taylor 
     Seattle Times aerospace reporter 

     An outside study of the National Transportation Safety Board
     (NTSB) says the agency is stretched precariously thin by
     increasingly complex plane-crash investigations, making it too
     reliant on the expertise of those with the most liability - airlines and

     The report by Rand, a Santa Monica, Calif., think tank, describes
     an agency "at or near the breaking point" in terms of staff
     workload. Moreover, a "lack of training, equipment and facilities
     has placed the NTSB's ability to independently lead investigations
     of major commercial aviation accidents at risk," it says.

     The "party system" of investigation, through which the safety
     board taps the expertise of involved companies, such as Boeing,
     and unions remains necessary, the report says, even though the
     companies have an interest in the outcome. The rationale is that no
     one understands a complicated airplane better than the people
     who built it.

     But the NTSB needs to increase its own expertise and capability
     and should consult disinterested experts more often to ensure that
     parties to an investigation can't unduly influence NTSB findings,
     the study says.

     "Rand has found that, at least in certain complex types of
     accidents, the party system is potentially unreliable and that party
     representatives may be acting to further various interests beyond
     prevention of a similar accident," the report says.

     "NTSB investigations of major commercial aviation accidents
     have become nothing but preparation for anticipated litigation,"
     while the rules of participation in an investigation supposedly
     prohibit that, the report says.

     The Rand findings are not likely to surprise those in the
     aviation-safety field. The written report follows months of public
     discussion of the evolving study. Many will regard it as articulation
     of the obvious.

     Not all, however. Ron Hinderberger, Boeing director of airplane
     safety, denies that his company's participation in crash
     investigations is motivated by anything other than a desire "to find
     out what happened and why."

     "Our greatest liability is not the litigation that's going to occur as a
     result of an accident, but the safety of the entire fleet," he said,
     alluding to engineering changes that often result from crash

     Hinderberger agrees, however, with another Rand conclusion -
     that the NTSB staff is overworked.

     Today's report could be the credible documentation the safety
     board needs to get its budget increased.

     "I hope this will be a wake-up (call) to the people in Congress
     that this is a very important agency, and it holds a very important
     place in the safety equation," said Cynthia Lebow, who led the
     Rand study.

     The NTSB's fiscal 1999 budget was $55 million, about the list
     price of one single-aisle jetliner.

     Governed by a board of five political appointees, the NTSB is
     charged with investigating air and ground transportation accidents
     and pipeline failures and with recommending action to prevent
     them. It has no rule-making authority and is among the smallest
     federal agencies, with about 400 employees.

     Its challenges, the Rand report said, aren't entirely related to
     insufficient resources or the tension inherent in the party system.

     The NTSB does a poor job of managing what resources it has,
     does not keep records in a way that helps prevent accidents,
     intentionally and detrimentally insulates itself from the aviation
     industry and has archaic investigative methods, the report says.

     The party system, however, was the intended focus of the study,
     which NTSB Chairman Jim Hall requested last year.

     "The effective separation of the NTSB investigative process from
     the litigation process is an ideal that has little connection to the
     reality of current practice," Rand says.

     The report, based in part on many interviews of those inside and
     outside the NTSB, cites no specific cases of a party's behavior
     affecting the integrity of an investigation.

     However, Rand's Lebow said: "This is a common problem. Our
     purpose is not to point a finger at one party or another. It's as
     common to the Federal Aviation Administration as it is to an
     engine manufacturer or an aircraft manufacturer or an airline."

     In that context, the report could fend off a desire by some
     interested parties, including Boeing, to be involved in the latter
     stages of crash investigations, when the NTSB staff is analyzing
     the facts and writing its report. Rand says that letting parties have
     more say would only widen the credibility gap.

     The report also might deflect a contention by plaintiff attorneys
     that, as investigation participants, companies and the government
     have an unfair legal advantage. One possible balance to that -
     selecting a representative from among hundreds of relatives of
     those killed in a crash - would be problematic and likely violate a
     requirement that participants have technical expertise, Rand

     The report describes an agency with a good reputation and a
     proud staff but says investigators are overworked: Fifty-hour
     weeks are the norm, and peak workloads exceed 60 hours.

     "In significant ways, the NTSB is already at or near the breaking
     point," the study says.

     Said Hall, in a speech last month: "Probably the most important
     issue raised in the report indicates that complex and contentious
     accident investigations, such as the investigation into USAir Flight
     427, which crashed outside Pittsburgh in 1994, and the ongoing
     TWA Flight 800 investigation, are likely to be the norm in the
     future rather than the exception."

     Investigation of the USAir crash, which involved a Boeing 737,
     took more than four years and resulted in a circumstantially
     supported conclusion of a rudder malfunction.

     Investigation of the 1996 crash of Flight 800, a 747 that exploded
     in flight, continues, but the crash appears to have been caused by
     an internally ignited fuel-tank explosion. Boeing disagrees with that

                                            Chuck Taylor's phone-message number is 206-464-2465.