SAFETY IN THE SKIES: MASTER VOLUME MASTER SKIES: THE IN SAFETY Institute for Civil Justice • R Personnel and SAFETYSAFETY ININ THETHE SKIESSKIES SAFETYSAFETY Parties in NTSB The National Transportation Safety Board is arguably the most important independent transportation safety authority in the world; its accident investigation methods have become the international standard. in the However, recent high-profile commercial aviation mishaps have stretched the NTSB’s resources to the in the Aviation Accident limit and are testing the agency’s ability to unravel the kinds of complex failures that lead to such tragedies. Investigations: The NTSB’s mission is to investigate and establish the facts, circumstances, and probable cause of major MASTERMASTER VOLUMEVOLUME transportation accidents, and make safety recommendations to prevent similar accidents from happening SKIESSKIES again. As such, the agency’s findings can have tremendous economic impact. To determine probable cause, the NTSB relies on a “party” process involving manufacturers and operators, among others. The potential for a conflict of interest is always present when parties assisting in an investigation are also likely to be named defendants in related civil litigation. The NTSB’s leadership is crucial to ensuring unbiased analysis of the cause of an accident. In recognizing these enormous challenges, NTSB Chairman Jim Hall sought a critical examination of the agency’s ability to investigate major transportation accidents, and in particular commercial aviation accidents. Adopting a multidisciplinary approach, RAND used a variety of quantitative and qualitative research techniques to assess the NTSB’s operations and processes. This research, conducted in RAND’s Institute for Civil Justice, outlines a set of recommendations aimed at strengthening the party process, expanding the statement of causation, modernizing the agency’s investigative procedures and streamlining its internal processes, managing its resources and staffing more effectively, developing training opportunities, and improving its R&D facilities. This report offers the most complete Henning Ettedgui, Lebow, Sarsfield, Stanley, examination of the workings of the NTSB in the 30-year history of the agency. ISBN 0-8330-2931-2 52500 R Out of Spec LIAM P. SARSFIELD • WILLIAM L. STANLEY 9 780833 029317 MR-1122/1-ICJ CYNTHIA C. LEBOW • EMILE ETTEDGUI • GARTH HENNING - iii - THE INSTITUTE FOR CIVIL JUSTICE The mission of the RAND Institute for Civil Justice is to improve private and public decisionmaking on civil legal issues by supplying policymakers and the public with the results of objective, empirically based, analytic research. The ICJ facilitates change in the civil justice system by analyzing trends and outcomes, identifying and evaluating policy options, and bringing together representatives of different interests to debate alternative solutions to policy problems. The Institute builds on a long tradition of RAND research characterized by an interdisciplinary, empirical approach to public policy issues and rigorous standards of quality, objectivity, and independence. ICJ research is supported by pooled grants from corporations, trade and professional associations, and individuals; by government grants and contracts; and by private foundations. The Institute disseminates its work widely to the legal, business, and research communities, and to the general public. In accordance with RAND policy, all Institute research products are subject to peer review before publication. ICJ publications do not necessarily reflect the opinions or policies of the research sponsors or of the ICJ Board of Overseers. - iv - BOARD OF OVERSEERS Chair: Ronald L. Olson, Munger, Tolles & Olson Harris Ashton Sheila L. Birnbaum, Skadden, Arps, Slate, Meagher & Flom Stephen J. Brobeck, Consumer Federation of America James L. Brown, Center for Consumer Affairs, University of Wisconsin-Milwaukee Kim M. Brunner, State Farm Insurance Arnold I. Burns, Arnhold and S. Bleichroeder Alan F. Charles, RAND Robert A. Clifford, Clifford Law Offices N. Lee Cooper, Maynard, Cooper & Gale Gary L. Countryman, Liberty Mutual Insurance Company John J. Degnan, The Chubb Corporation Christine Meaders Durham, Utah Supreme Court Paul G. Flynn, Los Angeles Superior Court Kenneth C. Frazier, Merck & Company William B. Gould IV, Stanford Law School Arthur N. Greenberg, Greenberg Glusker Fields Claman & Machtinger James A. Greer II Terry J. Hatter, Jr., Chief U.S. District Judge, Central District of California Deborah R. Hensler, Stanford Law School Patrick E. Higginbotham, United States Court of Appeals, Fifth Circuit Douglas G. Houser, Bullivant Houser Bailey Roberta Katz, Article III Steven J. Kumble, Lincolnshire Management Joseph D. Mandel, University of California, Los Angeles Charles W. Matthews, Jr., Exxon Corporation Arthur R. Miller, Harvard Law School Paul S. Miller, Pfizer Robert W. Pike, Allstate Insurance Company Thomas E. Rankin, California Labor Federation, AFL-CIO Bradford W. Rich, United Services Automobile Association Robert B. Shapiro, Pharmacia Larry S. Stewart, Stewart, Tilghman, Fox & Bianchi - v - CONTENTS THE INSTITUTE FOR CIVIL JUSTICE ............................... iii BOARD OF OVERSEERS ............................................. iv CONTENTS ........................................................ v FIGURES ........................................................ ix TABLES ......................................................... xi PREFACE ...................................................... xiii ACKNOWLEDGMENTS .............................................. xvii ABBREVIATIONS ................................................. xxi SUMMARY ....................................................... xxv CHAPTER 1: INTRODUCTION ......................................... 1 A NATIONAL FOCUS ON AIR SAFETY ............................... 2 THE ROLE OF THE NTSB IN AVIATION SAFETY ...................... 4 OBJECTIVES OF THE STUDY ...................................... 6 RESEARCH APPROACH ............................................ 9 CHAPTER 2: THE NTSB’S ROLE IN AVIATION ACCIDENT INVESTIGATION AND NTSB’S OPERATIONAL BASELINE ................................ 13 INVESTIGATING A MAJOR COMMERCIAL AVIATION ACCIDENT .......... 13 The Party Process ........................................ 16 The Team Approach ........................................ 18 PUBLIC HEARINGS AND ACCIDENT REPORT PREPARATION ............. 19 Follow-Up Activities ..................................... 20 Notation Draft and Board Meeting ......................... 22 INTERNATIONAL ACCIDENT INVESTIGATIONS ....................... 23 NTSB OPERATIONAL BASELINE ................................... 25 Operating Budget ......................................... 26 Staff Overview ........................................... 28 Accident History ......................................... 29 CHAPTER 3: EMERGING AVIATION TRENDS: POTENTIAL IMPACT ON AIRCRAFT ACCIDENT INVESTIGATIONS ............................ 37 IMPROVING THE SAFETY AND EFFICIENCY OF AVIATION ............. 37 National Aviation Safety Goals ........................... 39 The Safety Research Agenda ............................... 42 Accelerated Introduction of New Safety Technology ........ 43 GROWING COMPLEXITY IN AVIATION: IMPLICATIONS FOR THE NTSB ... 49 Increasing Reliability of Aircraft and Ground Systems .... 50 Design-Related Accidents: A Growing Danger ............... 51 NTSB Will Need New Investigative Methods ................. 55 THE CHANGING COMPOSITION OF THE TRANSPORT FLEET ............. 61 Diversity of Aircraft Types and Systems .................. 62 Larger Aircraft with Higher Passenger Densities .......... 63 The Aging Fleet .......................................... 65 - vi - TRENDS IN GENERAL AVIATION .................................. 73 NEW USERS OF THE NATIONAL AIRSPACE SYSTEM ................... 78 CHAPTER 4: AIRCRASH LITIGATION: THE LIABILITY ENVIRONMENT IN WHICH THE NTSB OPERATES ..................................... 81 CHARACTERISTICS OF AIR CRASH LITIGATION ..................... 82 THE CHANGING FACE OF AVIATION LITIGATION .................... 85 Fewer Early Settlements .................................. 86 Fact-Finding Through Litigation .......................... 87 Contested Liability ...................................... 88 Escalating Jury Awards and Insurance Settlements ......... 88 The Use of NTSB Materials in Civil Litigation ............ 89 NTSB Reports Are “Roadmaps to Liability” ................. 97 EVALUATING THE PARTY PROCESS ................................ 99 The Role of Parties ...................................... 99 The Role of Parties in Fact-Finding ..................... 103 Family Representation in Investigations ................. 105 Proposals to Extend the Parties’ Role to the Analysis Phase of the Investigation .............................. 109 Enhancing the Party Process ............................. 111 DETERMINING PROBABLE CAUSE ................................. 113 The Primacy of the Probable Cause Finding ............... 120 Restructuring the Probable Cause Finding ................ 126 CHAPTER 5: STAFFING, WORKLOAD, AND TRAINING AT THE NTSB ....... 131 STAFFING ................................................... 132 Characteristics of the Workforce ........................ 133 Salary Comparisons with Industry ........................ 142 WORKLOAD ................................................... 146 Aggregate Workloads ..................................... 146 Trends