Every NTSB investigation starts with a phone call and ends, ideally, with someone else changing how they do business. In between sits a process the agency describes as having five broad stages: the initial notification and decision to investigate, fact gathering on site, analysis and a probable cause finding, acceptance of a final report, and the push for safety recommendations. The NTSB is careful to add that the stages are not strictly linear. Investigators may be waiting on logbooks while they work through weather data, or an engine performance readout may send them back to the manufacturer with new questions.
Deciding to go
The board’s leadership decides whether to launch once it hears of an accident. Usually that happens right away. Sometimes the NTSB comes in later, when a critical safety issue turns up during someone else’s investigation. Jurisdiction has limits. The agency covers accidents on U.S. territory, and in international waters when U.S. flag vessels or U.S.-registered aircraft are involved. In marine cases the Coast Guard normally leads and the NTSB supports on safety. If a crash looks criminal, the lead passes to local police or the FBI. The NTSB says it does not investigate criminal activity; its focus is transportation safety and probable cause.
On scene
This is where the Go Team comes in. An investigator or team travels to the site, but the work also happens elsewhere: flight logs, maintenance records, personal interviews. Under what the NTSB calls the Party System, other organizations or companies can be named as parties to an investigation, which lets the board stretch its resources over roughly 1,200 aviation accidents and incidents every year, plus about 60 in rail, highway, marine and pipeline combined. Sometimes it holds an investigative hearing to pin down facts.
Analysis, then the report
Specialists work out the order of events and what caused them. A writer-editor who knows the technical vocabulary of that mode of transportation drafts the report, which describes the accident, reviews the analysis and states a probable cause. Approval comes either from a modal office director under delegated authority or at a public meeting of the Board Members. After adoption, the final version is prepared for public release. The NTSB generally aims to finish within 12 to 24 months, though complexity and workload can stretch that.
The part after the cause
A probable cause is not the finish line. Many investigations expose safety problems that the agency addresses through recommendations, aimed at regulators, manufacturers, state and local governments, companies and others in the field. After issuing them, NTSB staff keep in contact with recipients to track progress and advocate for adoption.
The independence behind all of this is written into the agency’s own description of itself. It has five Board Members, each nominated by the President and confirmed by the Senate for five-year terms, and the President designates one as Chairman and another as Vice Chairman for three-year terms. The NTSB traces its roots to the Air Commerce Act of 1926, which gave the Commerce Department the job of investigating aircraft accidents, and later to the Civil Aeronautics Board’s Bureau of Aviation Safety in 1940. Today it has approximately 400 employees, in Washington and field offices in Aurora, Federal Way and Anchorage.
