Planes, Trains & Automobiles – Lessons from the NTSB

, director, Nuclear Safety Project | August 11, 2015, 6:00 am EDT
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Nuclear Energy Activist Toolkit #61

Planes, Trains & Automobiles is a 1987 comedy film starring Steve Martin and the late John Candy. The title also describes several of the travel modes that the National Transportation Safety Board (NTSB) investigates when things go wrong.

NEAT 61 Figure 1 NTSB LogoLike the NRC, the NTSB is an independent federal agency. But unlike the NRC, the NTSB’s assessments of aircraft crashes, train derailments, pipeline explosions, and other accidents generally produce unassailable conclusions about their causes and the fixes that are necessary. As a comprehensive Rand Corporation report  from 2005 explained:

The National Transportation Safety Board (NTSB) plays a central role in the overall equation of aviation safety. The agency enjoys the reputation of being the most important independent safety investigative authority in the world; the caliber of its investigations has become the international standard. The NTSB is considered to be the best in the business and has served as a model for independent investigative authorities in many countries.

I examined the NTSB to see whether its processes for investigating accidents and documenting results contained lessons transferrable to the NRC.

NTSB’s Background

The origins of the NTSB date to the Air Commerce Act of 1926 that tasked the U.S. Department of Commerce with investigating aircraft accidents. That responsibility was transferred to the Civil Aeronautics Board’s Bureau of Aviation Safety when it was created in 1940.

President Lyndon Johnson asked the Congress for legislation that would consolidate several agencies and be headed by a cabinet-level official. Congress responded to his request by passage of Public Law 89-670 in October 1966 that created the U.S. Department of Transportation (DOT) and the NTSB within it.

But tasking the NTSB with investigating aviation, marine, highway, rail, and pipeline accidents could identify deficiencies in the DOT’s oversight of these areas. Congress concluded that “No federal agency can properly perform such (investigatory) functions unless it is totally separate and independent from any other … agency of the United States” and passed the Independent Safety Board Act of 1974 (Public Law 93-633) on January 3, 1975. When signed into law, it removed the NTSB from the DOT and established it as an independent agency.

Identical to the NRC, the NTSB is headed by five Commissioners appointed by the President and confirmed by the U.S. Senate for five-year terms with no more than three members belonging to the same political party. The NTSB employs about 400 individuals, about one-tenth of the NRC’s staff (albeit not an apples-to-apples comparison given that the two agencies have significantly different scopes of work.)

NTSB’s Investigative Process

The NTSB investigates nearly 2,000 aviation incidents each year and about 500 accidents involving other transportation modes—a work load too large for the NTSB’s staff to handle alone. The NTSB supplements its staff when necessary using the party system as described below.

The “Go Team” starts the NTSB’s investigations. NTSB staffers rotate through being on the duty roster where they can receive directions, day or night, to head ASAP to an accident scene. The Go Teams consist of specialists responsible for individual aspects of the investigation. For example, the Go Team investigating an aircraft crash might include members specializing in the airframe’s structure, engine performance, air traffic control and communications, weather, and human performance. These specialists head working groups that probe deeply into the areas. The working groups are staffed by representatives of the involved parties—the Federal Aviation Administration, the airline, the pilots and flight attendants unions, the engine manufacturer, and so on.

The inclusion of parties who might bear some culpability in the accident’s cause is tempered by this part of the Independent Safety Board Act of 1974: “No part of any report of the Board, relating to any accident or the investigation thereof, shall be admitted as evidence or used in any suit or action for damages growing out of any matter mentioned in such report or reports.” Thus, all parties to investigations have incentives for full and complete disclosures to the NTSB because doing so forces potential plaintiffs to find alternate ways of producing the same facts and conclusions. The NTSB’s final reports serve as roadmaps used by counsels for both plaintiffs and defendants in liability lawsuits, but the NTSB’s enabling act puts bumps in the those roads.

The NTSB’s investigative purpose is forward-looking instead of backward-looking. Its investigations seek to find causes rather than to find faults. Its investigations seek to identify recommendations to prevent future recurrences rather than to assign blame for past occurrences.

The NTSB’s investigations result in final reports that are publicly available.

NTSB’s Limitations

The NTSB’s mission is to promote transportation safety by preventing accidents. But its enabling legislation confines that mission to the reactive mode of investigating accidents. The NTSB’s accident investigations produce recommendations that can promote safety by reducing recurrences. But the NTSB’s ability to promote safety by identifying adverse trends that increase the chances for accidents is limited—until the accidents happen. Likewise, the NTSB’s ability to observe exemplary safety practices that should be applied broadly across an industry is equally restricted—again, until accidents provide opportunities for the NSTB to package such exemplary practices among its safety recommendations.

The NSTB lacks authority to implement any of its safety recommendations. For example, if the NTSB’s investigation of an aircraft crash recommends steps X, Y, and Z to prevent future crashes, only the Federal Aviation Administration can compel those steps to be taken. It is aninherent consequence of having independent investigations. While the NTSB lacks authority, its credibility provides considerable leverage to have its recommendations implemented.

The thoroughness of the NTSB’s investigations is the key to the credibility of its findings and conclusions, but it also has consequences. The NTSB strives to issue its final reports within a year of the accidents. But the growing complexity of accidents often requires more time. For example, the investigation into the crash of TWA Flight 800 after take-off from a New York City airport took nearly four years to complete. Obviously, if there’s a common cause for an accident, the sooner it is identified and corrected the less likely it is to factor in other accidents. The NTSB’s process recognizes this timeliness aspect and permits safety recommendations to be issued prior to final reports being completed.

Advantage – NTSB

NEAT 61 Figure 1 NTSB LogoBoth the NTSB and the NRC investigate accidents and incidents. Both investigations could involve deficient safety regulations and/or oversight that played roles. The NTSB avoids potential conflict-of-interest issues by being separate from the organizations with those responsibilities. In fact, the Independent Safety Board Act extracted the NTSB from DOT specifically to avoid such conflicts.

The NRC’s investigations can suffer from the same issues the NTSB faced when it functioned within the DOT. It is very hard, bordering on impossible, for NRC investigators to identify poor regulatory performance months or years ago by individuals who are now senior managers within the agency in positions from which to exact revenge.

The NRC could better protect itself from charges that its investigations give the agency such passes by formal involvement of the Advisory Committee on Reactor Safeguards (ACRS). The ACRS was established by the Atomic Energy Act of 1954. It reports directly to the NRC’s Chairman and Commissioners, making it independent of the NRC’s staff. As a minimum, the ACRS should review all Special Inspection Team (SIT), Augmented Inspection Team (AIT), and Incident Investigation Team (IIT) reports issued by the NRC and formally comment on their completeness. The NRC only conducts six to ten such investigations yearly, so the proposed review by ACRS entails a minimal resource burden.

The ACRS’s involvement could be expanded to participating, in an observer role, in the onsite investigations conducted by the NRC’s SITs, AITs, and IITs. The ACRS need not participate in every onsite investigation, but it should have the option to participate when time and interest permits.

The ACRS should also periodically review the Differing Professional Opinions (DPOs) and Non-Concurrences (NCRs) initiated by NRC staffers. The NCR process allows a NRC reviewer, such as a member of an AIT or subject matter expert, to decline to sign a draft NRC document he or she has been tasked with reviewing. The DPO process allows NRC staffers to contest decisions made by NRC management. The NCR and DPO processes each require the NRC to respond in writing to each issue raised.

Because individuals initiating DPOs and NCRs can request confidentiality and the ACRS operates under the public access provisions of the Federal Advisory Committee Act, some care would be needed to protect identities of those workers wishing to remain anonymous so as to not have the ACRS’s review deter workers from using these options.

Advantage – NRC

NEAT 61 Figure 3 NRC LogoAs previously mentioned, I examined the NTSB for lessons transferrable to the NRC. The examination also identified positive lessons where the NRC’s doing better than the NTSB. Two of the most positive lessons involve proactive safety recommendations and reducing the reliance on involved parties.

Both the NTSB and the NRC investigate accidents to extract lessons intended to prevent recurrences. The NRC supplements these reactive safety efforts with proactive efforts. One example among many is the NRC’s operating experience program. Through it, the NRC seeks to identify adverse trends as early as possible and intervene before they result in accidents. The NRC’s study into failures of components operating past the vendor-recommended service lifetimes illustrates this proactive safety measure at work. One cannot count the number of accidents averted by proactive safety measures, but one can count on such measures to help reduce the chances of accidents.

The NTSB “deputizes” representatives of parties involved in accidents to actively participate in the investigations into what went wrong. The NTSB’s track record strongly suggests their checks and balances against conflict-of-interest biases have worked well. The NRC conducts its investigations in a manner less susceptible to perceptions of collusion and corruption from the outside. While gathering information from industry representatives during its investigations, the NRC does not permit these individuals to participate in its analysis of that information into what happened. If its in-house expertise cannot cover an aspect of an investigation, the NRC will call upon experts at the national laboratories. The NRC’s approach to investigations results in final reports that are more clearly free from biases by parties with vested interests to protect.

To be fair to the NTSB, its investigations cover a far wider array of actors and equipment than the NRC encounters. The nuclear power industry in the United States features a small handful of reactor designs operated by a relatively small number of owners. With so many planes, boats, trains, railcars, cars, buses, trucks and pipelines in the United States, the NTSB would probably need to have a cast of thousands to have sufficient in-house expertise to maintain situational awareness of them all. Thus, the NTSB uses its party system, with its controls, to achieve the objective findings and conclusions in its reports that the NRC can reach via more direct means.

An advantage that the NTSB has over the NRC is that it is independent from the organization (e.g., FAA) tasked with enacting and enforcing safety regulations. Yet that independence comes at a price that the NRC does not have to pay. The NTSB’s independent investigations result in recommendations for safety upgrades, but the NTSB cannot compel any of its recommendations to be implemented. When the NRC’s investigations identify needed safety upgrades, it can unilaterally mandate that nuclear plant owner undertake them.

Bottom Line

I truly felt that an examination of the NSTB would yield a multitude of lessons transferrable to the NRC. In fact, when UCS convened last year to plan our activities during 2015, we thought the effort would result in a report of 10 to 20 pages chronicling our research and explaining the various lessons. That report would then support our “asks” of Congress and the NRC aimed at getting as many of the lessons implemented as possible.

The good news is that the examination yielded fewer transferrable lessons than we’d expected.

The better news is that the examination revealed more things that the NRC is doing better on than the NTSB, an outcome that doesn’t surprise us—in hindsight.

The NRC can up its game by involving the ACRS more formally in its accident and incident investigations, but that’s a smaller “ask” that we can, and will, pursue sans report.

 

The UCS Nuclear Energy Activist Toolkit (NEAT) is a series of post intended to help citizens understand nuclear technology and the Nuclear Regulatory Commission’s processes for overseeing nuclear plant safety.

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  • Sigma

    You note in your report:

    “An advantage that the NTSB has over the NRC is that it is
    independent from the organization (e.g., FAA) tasked with enacting and
    enforcing safety regulations. Yet that independence comes at a price that the
    NRC does not have to pay. The NTSB’s independent investigations result in
    recommendations for safety upgrades, but the NTSB cannot compel any of its
    recommendations to be implemented. When the NRC’s investigations identify
    needed safety upgrades, it can unilaterally mandate that nuclear plant owner
    undertake them.”

    The NRC can unilaterally mandate safety upgrades but why do they choose not too so often?! You have discussed a number of NRC failures to act in the past.

    Although the NTSB cannot compel its recommendations be implemented, it seems they are still far more effective in getting those recommendations instituted.

    But that being said, both the NTSB and the NRC are really only tombstone entities. People have to die so positive change can result.