other government agencies can match. The objective of this study is to understand the key factors
underlying the effectiveness of the NTSB so as to derive lessons that may be profitably applied to
other industries. Of course, we acknowledge at the outset that certain unique features of the
transportation industry contribute to the NTSB’s success. Transportation accidents are almost
always limited in scope and time, which makes it possible to conduct in-depth forensic1
investigations that result in concrete conclusions and actionable remedies. Such accidents are also
typically well-defined, with causes that are usually identifiable upon detailed examination,
allowing the NTSB to be largely reactive yet still highly effective. Finally, and perhaps most
significantly, no one benefits immediately from a transportation accident. Therefore, all
stakeholders are united in their desire to improve safety. As Jeff Marcus, an NTSB safety specialist,
put it, “You can trust people to be honest and moral about not killing themselves.” This last point
may seem obvious, but in other industries, certain parties may profit handsomely from crises that
inflict enormous pain on others. Despite these features of transportation, the NTSB’s enviable
record of success deserves further study to determine which of its methods are applicable to other
technology-based industries such as financial services, healthcare, and energy, all industries in
which “accidents” arise from the failure of complex systems, i.e., systemic risk. This is the
challenge we undertake in this article. By examining the structure and functions of the NTSB, and
studying a specific accident investigation in detail, we observe five major factors that seem to
characterize the agency’s success: (1) the governance structures that give rise to the agency’s
impartiality and singular focus; (2) the investigative “Go Team” as a cohesive unit; (3) the
collective intelligence of the NTSB’s “party system”; (4) effective media relations; and (5)
employee satisfaction. While some of the NTSB’s practices are indeed specific to the
transportation industry, we believe that the most important drivers of its success can be adapted to
other industries and contexts. We begin in Section 2 by providing a brief organizational overview
of the NTSB. In Section 3, we focus on the most important aspect of the NTSB: its accident-
investigation process. To illustrate how this process works, we present a case study of the NTSB’s
investigation of the Minnesota I-35W highway bridge collapse in Section 4. Based on this example
and other observations, we summarize the organizational factors that contribute the most to the
success of the NTSB in Section 5. In Section 6, we consider some of the current challenges facing
the NTSB, and we conclude in Section 7.
4.4.1.The NTSB organization:
The NTSB can be traced back to the Air Commerce Act of 1926, which eventually led to the
establishment of the Civil Aeronautics Board’s Bureau of Safety in 1940. Beginning in 1967, the
NTSB emerged as an independent agency within the Department of Transportation (DOT), and
was later reestablished as a completely independent entity outside of DOT by Congress through
the Independent Safety BoardAct of 1974 (see Appendix A.1 for key facts and figures of the
NTSB). A lean organization of about 400 employees, the NTSB is charged with investigating
every civil aviation accident and all significant highway, marine, railroad, pipeline, and hazardous-
materials accidents. From these investigations, the NTSB first identifies the cause of the accidents
and, thereafter, develops safety recommendations for preventing similar accidents in the future.
Significantly, the NTSB has no regulatory authority; the Federal Aviation Administration regulates
the airline industry, the National Highway Traffic Safety Administration and the Federal Motor
Carrier Safety Administration regulate motor vehicle transportation, the United States Coast Guard
regulates civil waterborne transportation, and the Pipeline and Hazardous Materials Safety
Administration regulates pipelines and hazardous materials. The NTSB is primarily responsible