The National Transportation Safety Board Aviation Safety Course

NTSB Definition

The National Transportation Safety Board is an independent agency of the U.S. government that determines the probable cause of transportation accidents and promotes transportation safety through the recommendation process.

To help prevent accidents, the NTSB develops and issues safety recommendations to other government agencies, industry, and organizations that are in a position to improve transportation safety. 

NTSB Mission

The NTSB states its mission is to promote transportation safety by:

Maintaining its congressionally mandates independence and objectivity.
Conducting objective, precise accident investigations and safety audits.
Performing fair and objective airman and mariner certification appeals.
Advocating and promoting safety recommendations.
Assisting victims of transportation accidents and their families through Transportation Disaster Assistance (TDA).

Origins of the NTSB

The Air Commerce Act of 1926, congress charged the Department of Commerce with investigating the causes of aircraft accidents. Later that Responsibility was given to the Civil Aeronautics Board's Bureau of Aviation Safety.

In 1967, Congress consolidated all transportation agencies into a new Department of Transportation and established the National Transportation Safety Board as an INDEPENDENT agency within the department.

With the passage of the Independent Safety Board Act of 1974, Congress made the NTSB completely independent outside of the DOT, because

No federal agency can properly perform such investigatory functions unless it is totally separate and independent from any other..agency in the United States.

NTSB Organizational Chart

NTSB Top Level

Five board members, each nominated by the U.S President and confirmed by the Senate to serve 5-year terms. A Chairman and a Vice Chairman are designated from these of five board members. NTSB board members establish policy on transportation safety issues and on NTSB goals, objectives and operations.

NTSB Second Level

The following offices report to the Chairman of the NTSB:

  • The Office of the Chief Financial Officer
  • The Office of the General Counsel
  • The Office of the Managing Director
  • The Office of Communications
  • The Office of Equal Employment Opportunities (EEO)

NTSB Third Level

The following offices report to the NTSB Managing Director:

  • The Office of Research and Engineering
  • The Office of Railroad, Pipeline,and Hazardous Materials Investigations
  • The Office of Aviation Safety
  • The Office of Highway Safety
  • The Office of Marine Safety
  • The Office of the Chief Information Officer
  • The Office of Administration
  • The Office of Administrative Law Judges

Office of Aviation Safety

The Office of Aviation Safety has the responsibility for investigating aviation accidents and incidents and for proposing probable causes for the Board's approval. Most of the field investigations are led by a regional investigator from one of the four offices:

  • Eastern Region
  • Central Region
  • Western Pacific Region
  • Alaska Region

Aircraft Accident Statistics

From 1959 to 2016 there were 744 million departures with a total of 1,389 million flight hours flown worldwide.

Why Investigate?

We investigate accidents to prevent future ones. The future accidents that are to be prevented do not necessarily have to look like the one that is being investigated. The major objective for investigating accidents is identifying hazards, and those hazards discovered need to be addressed through safety risk management, whether they actually were important to the accident in question or not, since they could create future accidents.

What is a Finding?

Findings are the factors that contributed significantly to the accident. ICAO define findings as "all significant conditions and events, causal and non-causal, found in an investigation."

What is a Cause?

A cause is a finding singly or in combination with other causes, resulted in the damage or injury that occurred. A cause is also deficiency which if corrected, eliminated, or avoided, would likely have prevented or mitigated the damage or injuries associated with an accident or incident.

Three- Step Causation Test

Some investigators ask themselves three questions to test if a finding is indeed causal. If all three answers to the questions are "yes", then finding likely helped cause the event. The three questions are as follows:

  • Did the finding start or sustain the accident sequence?
  • If the finding had not existed, would the accident likely have been prevented?
  • If the finding is related to human performance, is it reasonable to expect that a human would have behaved otherwise?


Recommendations are the single most important takeaway from the accident investigation since the whole purpose of investigating the accident is to prevent future accidents. Investigators want to eliminate other accidents from happening with the same causes, and therefore, work diligently to identify the deficiencies that need correction.

Accident Investigation Process

When a major commercial aviation accident occurs, an NTSB go-team, led by an investigator-in-charge (IIC), is dispatched from the agency's Washington, D.C headquarters to the accident site, usually within a couple of hours of notification of the event. The IIC, a senior air safety investigator with the NTSB's Office of Aviation Safety (OAS), organizes, conducts, and manages the field phase of the investigation, regardless of whether a board member is also present on the scene.

The Go-Team

On 24-hour alert, go-team personnel possess a wide range of accident investigation skills. For aviation accidents, a go-team roster could include one of the five members of the NTSB, an air traffic control specialist, a meteorologist, a human-performance expert, an expert trained in witness interrogation, an engine specialists, as well as experts in hydraulics, electrical systems, and maintenance records.

Accident Site

The length of time a go-team remains on the accident site varies with need, but generally a team completes its work in 10 to 14 days. However, accident investigations often can require off-site engineering studies or laboratory tests that might extend the fact-finding stage. In cases of crew fatalities, a local coroner usually performs autopsies on the flight crew to determine at the outset whether pilot in-capacitation might have been a factor. An autopsy can also reveal who was sitting where in the cockpit and who was flying the aircraft.

  • Human-performance specialists examine the background and performance of persons associated with the circumstances surrounding an accident, including the person's knowledge, experience, training, physical abilities, decisions, actions and work habits.
  • Aviation engineering experts in four areas provide strong technical investigative skills. Power plant specialists examine the airworthiness of aircraft structures and flight controls as well as the adequacy of design and certification.

Accident Report Preparation

Following completion of the on-scene phase of the investigation (which may last for several days or weeks), each NTSB group chair (the senior investigator over-seeing a specific area of the investigation) completes a factual report on his or her area of responsibility.

Public Hearing

Following an accident, the NTSB might decide to hold a public hearing to collect added information and to discuss at a public forum the issues involved in an accident. Every effort is made to hold the hearing promptly and close to the accident site.

Final Accident Report

With the completion of the fact-finding phase, the accident investigation process enters its final stage-analysis of the factual findings. The analysis is conducted at the NTSB's Washington,D.C, headquarters. The final accident report includes a list of factual finding concerning the accident, analysis of those findings, recommendations to prevent a repetition of the accident, and a probable-cause statement.

Safety Recommendations

The Safety Recommendations made to the FAA is the NTSB's end product. Nothing takes a higher priority, and nothing is more carefully evaluated. In effect, the recommendation is vital to the NTSB's basic role of accident prevention because it is the lever used to bring changes an improvements in safety to the nation's transportation system. Recommendation are based on findings of the investigation and may address deficiencies that do not pertain directly to what is ultimately determined to be the cause of the accident.

Family Assistance and The Transportation Disaster Assistance Office

Following the enactment of the Aviation Disaster Family Assistance Act of 1996, the president designated the NTSB as the lead federal agency for the coordination of federal government assets of the science of a major aviation accident and as the liaison between the airline and the families.

NTSB Accident Databases

The NTSB aviation accident database and synopses, which go back as far as 1962, are available online at http://www.ntsb.gov. These databases contain information on civil aviation accidents and selected incidents that occur within the shores of the United States, within its territories, and in international waters.

10 Aircraft Accidents that Changed the World

For this week you were asked to go to the NTSB Aviation Accident Database and pick an aircraft accident of your choice. Your in class discussion should include: Who, What, Where, When and Why the aircraft accident or incident occurred and the lessons learned from such accident.

NTSB Most Wanted Aviation Safety Improvements

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