The National Transportation Safety Board issued its 2019 “Top 10 Most Wanted Safety Improvements” to help prevent accidents and save lives. But how did NTSB choose these particular issues?
NTSB had a systematic method to determine what makes the list, but in some cases, it’s unclear how they used their criteria to make the selections. If advocacy groups, industry associations and others don’t know why NTSB is advocating for these particular safety issues and recommendations, that could affect their attention to and support for tackling the issues on the list.
We recommended that NTSB better document and communicate its decisions for the list.
Two NTSB workers viewing smoking wreckage
What GAO Found
The National Transportation Safety Board (NTSB) developed a multiphase approach to select issues for its 2019–2020 Most Wanted List of Transportation Safety Improvements (see figure). NTSB designed the selection process to encourage collaboration and to consider the expertise of NTSB's four modal offices (Aviation Safety, Highway Safety, Marine Safety, and Railroad, Pipeline, and Hazardous Materials) and its Office of Research and Engineering. Like past lists, each issue must be supported by one or more open safety recommendations. The process also allowed NTSB's board members and others discretion in suggesting changes to the issues proposed for inclusion on the Most Wanted List. NTSB uses the list to raise awareness of its recommendations and to advocate their adoption since the NTSB cannot require implementation of its recommendations.
National Transportation Safety Board's Selection Process for Its 2019–2020 Most Wanted List of Transportation Safety Improvements
NTSB published a methodology report, in response to the requirements in the National Transportation Safety Board Reauthorization Act of 2018, that detailed the methodology to evaluate and select issues for the list. GAO found that the design of NTSB's methodology met the essential components for designing a sytematic deicision-making framework. When implementing that methodology, however, NTSB did not fully document how staff, when evaluating the issues, considered its own established criteria nor fully communicated the rationale for why its selected issues were “ripe for action” now—a key component of the list . While GAO was able to determine the rationale for NTSB's evaluation and selection decisions, NTSB's guidance does not require NTSB to fully document or communicate its decision, and NTSB does not do so. Greater transparency in how issues are evaluated and selected could enhance users' understanding of the list and help ensure the list continues to rally the support and resources needed to tackle difficult and long-standing transportation safety challenges.
Why GAO Did This Study
NTSB investigates accidents across all modes of transportation and issues recommendations intended to prevent similar accidents. In 2019, NTSB published its latest Most Wanted List of Transportation Safety Improvements. It identified 10 transportation safety issues with 268 underlying safety recommendations.
The National Transportation Safety Board Reauthorization Act of 2018 included a provision for GAO to examine NTSB's methodology for evaluating and selecting recommendations for inclusion in the Most Wanted List. This report discusses (1) NTSB's methodology for developing its Most Wanted List and (2) how NTSB addressed statutory requirements and how its methodology aligned with components for systematic decision-making, among other objectives. GAO reviewed NTSB documentation for its process of selecting issues for the Most Wanted List. GAO also interviewed NTSB officials to understand the rationale behind the selection methodology and how the process was applied. GAO compared the methodology to essential components for systematic decision-making and the statutory requirement that NTSB publish a publicly available methodology report that describes NTSB's consideration of key elements.
Reissued with revisions on Mar. 19, 2020.This report was revised on March 19, 2020 to include the National Transportation Safety Board’s letter commenting on the draft report as appendix III, on page 32.
GAO recommends NTSB improve how it documents and communicates decisions for its Most Wanted List. NTSB agreed with both recommendations.
Recommendations for Executive Action
|National Transportation Safety Board||1. The Chairman of the Board should require the Safety Recommendation and Communication team to fully document its evaluations when assessing items to propose for Most Wanted List consideration (Recommendation 1).|
|National Transportation Safety Board||2. The Chairman of the Board should take steps to publicly and fully communicate the selection rationale, such as including why NTSB believes an issue is "ripe for action" to its documentation on its website (Recommendation 2).|