Inside the Investigation: The NTSB’s Culture of Transparency and Integrity
It was supposed to be a routine trip. Loaded up with cargo, the El Faro disembarked from Jacksonville, Florida, on 29 September 2015 en route to San Juan, Puerto Rico. Thirty-three crew members were onboard the ship, traveling at roughly 20 knots with a plan to stay south of a storm making its way through the area.
That trip, however, became anything but routine when the El Faro sailed into Hurricane Joaquin, lost propulsion, and sank. Everyone onboard died. And there was no certainty about where the ship itself went.
The maritime disaster launched one of the largest post-crash investigations in the history of the U.S. National Transportation Safety Board (NTSB). With assistance from branches of the U.S. military, the NTSB worked to find out why the ship sailed into the hurricane, what happened to the crew, and what could be done to prevent a similar incident from occurring again.
Mandated by the U.S. Congress to promote a higher level of safety in the transportation system, the NTSB carries out its mission through investigations into accidents and crashes, as well as issuing reports with safety and security recommendations. This independent agency maintains several hundred investigators on staff and conducts thousands of investigations each year into incidents involving the different modes of transportation: aviation, maritime, rail, and traffic. In addition to investigators, the board has a research and engineering office—with specialists in fire forensics, medicine, and even metallurgy.
Brian Curtis, deputy managing director for investigations of the NTSB and former director of the NTSB Marine Safety Office, has been with the NTSB for 19 years—his first nine to 10 years were spent as an investigator in the marine mode, including working on the El Faro investigation. The NTSB worked with its partners, including the U.S. Coast Guard, for two years to find the El Faro, recover its black box, and put together a comprehensive report about what happened from the moment the ship left Jacksonville until it sank beneath the ocean waves.
“You get a call one night that there’s a ship missing. Two years later to have a very comprehensive report with a lot of good recommendations in a lot of areas to improve the safety of shipping was amazing,” Curtis says. “We do that across all the NTSB modes, and that all comes from open-mindedness and determination to get all the facts related to any investigation.”
After extensive analysis and research, the NTSB determined that the probable cause for the sinking of the El Faro was the captain’s “insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew,” according to the executive summary of the investigation report. “Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions.”
The NTSB also identified a host of safety issues, which also led to the loss of the ship and everyone onboard the vessel. The NTSB made 53 safety recommendations after finishing the investigation to prevent other crews and ships from meeting a similar fate, 14 of which were considered acceptable actions and implemented as of Security Management’s press time.
To learn more about the work the NTSB does and best practices for investigators seeking to share the findings of their work, Security Management Senior Editor Megan Gates spoke with Curtis about the board’s organizational culture, positive attributes for investigators, and more. Their conversation has been slightly edited for clarity.
SM. You’ve been with the NTSB for quite a while. What is the organizational culture like?
BC. We strive for transparency, and that helps us immensely in our investigations. We put out a lot of reports, and we strive, of course, for accurate reports, thorough reports, and, as best we can, timely reports. I think that’s the big picture. With about 400 people in the agency in all, about 135 of those are investigators.
There is more staff that provides support for the investigations, research, and engineering, and the likes of that. We do about 1,300 or 1,500 investigations per year across all the modes. We’ve done, I think, in excess of 150,000 investigations over the years. We have a good history to pull from as we work to hone our processes, efficiencies, and quality of reports.
SM. As part of that transparency effort, NTSB shares its investigative process on its website that walks readers through how an investigation is conducted. Has this process evolved or changed over time?
BC. Certainly, it’s a constant evolutionary process. As we find challenges to our system, we’re always looking for better processes. It all starts with not really a secret sauce. We just have a lot of good talent. We’re constantly learning. We try to be very transparent with a lot of humility and always honing our process with time as we move along.
Most of our investigators, they come to us as second-career professionals—regardless of the mode. They bring in the industry experience and knowledge and professionalism, then we just have to hone their craft as investigators collecting evidence, development, and reports—analyzing all that. We’re always honing our processes, both agency-wide and mode-specific, to make them better quality reports. You have to have an accurate report.
We thrive on transparency, which produces the accuracy of the reports, the thoroughness, and timeliness.
We also use a party system, which is valuable to us. We can’t be all-knowing on all things. When we have investigations, we bring in parties—organizational specialists from the manufacturers, unions, and the likes of that—to help us collect the evidence. They help us conduct the interviews and identify evidence. We do our own analysis. We have a lot of processes that are inward facing. We also use the industry to help us collect the evidence, identify the evidence, and, as I say, even conduct the interviews.
It’s worked well for us. We eventually develop factual reports of all things that we collected on scene. The parties help us even review those factual reports for accuracy and omissions and errors and whatnot, which eventually leads us to our analysis. It’s critical to get parties involved, to get the NTSB involved, and then follow a process through the report production. We like to be open and transparent to make sure we’ve collected the evidence. We have a public docket system. We put all the relevant information to that investigation, it’s captured in the docket to records, and we use that in the development of the reports.
SM. You mentioned bringing in organizational specialists and people to assist with an investigation. Is there a process the NTSB uses to vet those individuals or that you use to identify when you need outside help?
BC. That’s left up to the individual NTSB investigator in charge for the accident. It’s outlined in our regulations, the party system. The investigator in charge, once he or she gets on scene, they can identify the manufacturer or some piece of equipment or if they say it’s some union…identifying who we may want to interview.
The party system is critical in the process to make sure we get well-rounded evidence collection, because ultimately the report is based on all of the evidence and documentation we collect.
SM. As you said, many NTSB investigators come to the board as a step in their second career. Is there anything similar that you see in people’s backgrounds that makes them a good investigator?
BC. What we like is, of course, the broad experience of knowledge from the industry they’re coming from and mode if you will, but also that they’re very open-minded. We always encourage that for investigators. When you get on the scene, you want to have very open-minded investigators because if you start to develop biases of what you think happened, you tend not to collect all the evidence.
In the hiring process, we’re looking for people with that experience, knowledge, but by the same token, have good communication skills, and open-mindedness as to what may have happened. It could’ve been anything. In all these investigations, it seems like, from the smallest ones to the largest ones, you get on the scene and sometimes you seem to get preconceptions about what happened, and oftentimes that’s not the case. We train in those aspects.
SM. A critical part of the investigation process is obviously gathering and collecting evidence, which sometimes requires people to be on site. Did the COVID-19 pandemic change the way that the NTSB conducted investigations?
BC. Early on in March of 2020 when all this started with COVID, we basically couldn’t launch teams for several months, but we still had to investigate. We have mandates and regulatory statutes to investigate these accidents. We still did collect information remotely and telephonically, and we worked with our regulatory agencies if they had somebody on scene to collect the information.
We started to do some launching in the June–July 2020 timeframe, as we closely monitored the COVID numbers. We could get people out, maybe even driving instead of flying because we had investigators located around the country.
Then by October, our investigators started traveling to sites again. We never missed a beat. During that timeframe where we were doing a lot of, if you will, at-desk investigations, we were collecting information early on. It allowed us—quite frankly—to focus on some of the older investigations.
We really started to ramp up in late 2020, early 2021—we were launching pretty much to most of the accidents that we would’ve pre-COVID. But I think we developed processes during COVID, when we were asking: How are we going to launch people? What are the trick points? Where can we go? How can we get there?
We still managed through all that to collect the evidence and conduct those investigations. Now we’re really back up to speed at this point. We’re under normal launching conditions, but always keeping a watchful eye for COVID if these variants come up.
SM. A key part of the NTSB process is advocating for safety recommendations based on the findings of your investigations. The NTSB, however, does not have regulatory authority to mandate an industry change. How does this dynamic change the work that you do? And how do you successfully advocate for an industry change?
BC. Over the years, we’ve issued in excess of 15,000 recommendations, and the positive acceptance rate is somewhere around 80 percent of these recommendations. As you say, we don’t have regulatory authority, but through our reputation for fair, honest, open investigations, I think that’s where we get up to that 80 percent acceptance rate.
We do outreach advocacy. We’ll go and talk to stakeholders in different industries about the recommendations, or they’ll invite us to come talk to them. We have a most-wanted list with 10 items on it that the presidentially-appointed board members get out and advocate for, as well as staff. We do a lot of advocacy work and explain to the industry the benefits of these recommendations.
The interviewees tell us what people have done, their thoughts, and their perceptions, but the technologies bolster all that when you piece it all together in the analysis.
We don’t make these recommendations blindly to incur financial costs or pain on people. We issue them to minimize the chance of recurrence of these accidents and crashes and incidents that ultimately injure or cause fatalities.
We have a whole safety recommendation office that follows the recommendations that are open and helps us guide us to the outreach and the advocacy to stay on top of that. We have a lot of people traveling to perform that advocacy in our efforts to get these implemented and successfully close all these recommendations.
SM. We’ve been witnessing a rise in distrust in organizations and experts. Do you have any advice or recommendations for investigators about sharing information and getting people to take your word that your report is accurate? That your findings are true?
BC. I think the biggest thing, is open-mindedness when you’re collecting the information, transparency of what you’re trying to do, and the integrity of your track record. I think we do a good job of just taking the facts, unbiased, and putting those out there. We basically live by integrity and adaptability. We’re humble at what we do, realize we’re not always perfect, but we’re always looking for ways to improve. We thrive on transparency, which produces the accuracy of the reports, the thoroughness, and timeliness. We like timely because the quicker you get the reports out there, the more relevant they are.
Sometimes they take a little more time, but as we hone our processes, hopefully, we can even improve the timeliness.
SM. Are there any other major lessons learned for you and the NTSB through some of the different work you have done recently?
BC. Now that I work with all the modes, I think just the way we attack investigations. We have our agency rules, unique individual modal processes we follow, and we developed an accident investigation manual across the modes. It’s one manual, which contains links to every step of the process for the investigator in charge to reference. We developed a program in-house where we can track all our investigations step-by-step, to help with the timeliness, the thoroughness, and to make sure we don’t miss any steps.
We also have recurring training for investigators. As we develop these processes, we get the investigators and the managers up to speed in these new processes. They have a lot of input in how they’re developed.
It’s just the open-mindedness across the modes. Every mode always has multiple ongoing investigations, and we like to keep those relevant current and timely, but at the same time accurate and thorough because when the recommendations come out of these reports, we want to make sure they’re impactful and we don’t want them to be unreasonable. At any given time, there’s over a thousand investigations going on, but every one of those investigations is an opportunity to improve our process.
I would also call out that we have a petition for reconsideration process, where if we put a report out and someone outside finds other facts that may alter the findings or the probable cause, they can submit a petition for that. It’s reviewed and if there is new evidence and we validate the petition, and we would reopen that investigation to take a look at see if we do need to change the probable cause of finding.
SM. Thinking back to your work on the El Faro investigation, what happens if you get to a point in an investigation where there’s not a way to get the information that you need to create a report?
BC. We don’t always have to have the probable cause that’s very explicit in what caused the event, but our issue is more around identifying issues that were involved and trying to improve on those. When you do 1,300 to 1,500 investigations a year, there are going to be those that you can’t get enough to get the probable cause explicitly, but certainly the issues are not always difficult to identify.
SM. How has technology changed how you conduct investigations and sometimes fill in those gaps?
BC. We’re always coming up with new technologies. Now, people think, well, technologies save time. Technologies don’t always save time, but technologies are always beneficial when it comes to what happened—whether it’s recordings, audio-visual, just the new technologies in evidence collection.
Technology often doesn’t change the investigation, but it will improve the timeliness and certainly improves the validity by vetting analysis of the evidence we collect.
SM. Thinking about technology and going back to the 1940s and 1950s, often the NTSB would have been relying on someone’s handwritten notes or a verbal account of what happened. Now we have technology, where sensors are built-in, and cameras and recordings can provide additional data to boost and enhance that investigation.
BC. Yes. We’ve always done live interviews, but interviews, especially with people involved in these events, often their recollection may not be that good. They’ve been through a traumatic event.
With the technologies, recordings, the flight data recorders, and all that—even in vehicles, you’ve got control modules that record—we can square that technology and the evidence that we collect with the interviews. The interviewees tell us what people have done, their thoughts, and their perceptions, but the technologies bolster all that when you piece it all together in the analysis.