# Issuing instructions - Type: NTSB finding subsection - Path: [Personnel issues](https://openairdocs.org/ntsb-findings/02) › [Task performance](https://openairdocs.org/ntsb-findings/0206) › [Communication (personnel)](https://openairdocs.org/ntsb-findings/020635) › Issuing instructions - NTSB code: 02063538 - Cases: 26 - In the probable cause: 20 - Fatal cases: 3 - All cases: https://openairdocs.org/ntsb-findings/02063538/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/02063538/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/02063538 ## Cases per year (in the probable cause / all) - 2008: 4 / 4 - 2009: 4 / 5 - 2011: 1 / 1 - 2012: 2 / 2 - 2014: 1 / 1 - 2016: 0 / 1 - 2017: 1 / 2 - 2018: 0 / 1 - 2019: 1 / 1 - 2021: 1 / 1 - 2022: 1 / 2 - 2023: 1 / 1 - 2024: 1 / 2 - 2025: 1 / 1 - 2026: 1 / 1 ## Defining events in these cases - [Collision during takeoff/land](https://openairdocs.org/ntsb-events/490): 3 cases - [Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260): 2 cases - [Midair collision](https://openairdocs.org/ntsb-events/250): 2 cases - [Cabin safety event](https://openairdocs.org/ntsb-events/110): 2 cases - [Air traffic event](https://openairdocs.org/ntsb-events/100): 2 cases - [Hard landing](https://openairdocs.org/ntsb-events/092): 2 cases - [AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081): 2 cases - [Airport occurrence](https://openairdocs.org/ntsb-events/070): 2 cases - [Turbulence encounter](https://openairdocs.org/ntsb-events/360): 1 cases - [Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342): 1 cases ## Aircraft models (registry) - [Cessna 172S](https://openairdocs.org/model/cessna-172s): 3 cases - [Sikorsky UH-60A](https://openairdocs.org/model/sikorsky-uh-60a): 1 cases - [Schweizer 269C](https://openairdocs.org/model/schweizer-269c): 1 cases - [Robinson Helicopter R44 II](https://openairdocs.org/model/robinson-helicopter-r44-ii): 1 cases - [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180): 1 cases - [Pilatus PC-12/45](https://openairdocs.org/model/pilatus-pc-12-45): 1 cases - [Airbus Industrie A320-232](https://openairdocs.org/model/airbus-industrie-a320-232): 1 cases - [Embraer ERJ 170-100 LR](https://openairdocs.org/model/embraer-erj-170-100-lr): 1 cases - [Embraer EMB-145XR](https://openairdocs.org/model/embraer-emb-145xr): 1 cases - [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22): 1 cases ## Other findings in the same cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 9 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 4 cases - [Expectation/assumption](https://openairdocs.org/ntsb-findings/02041525) (Personnel issues): 3 cases - [Use of equip/system](https://openairdocs.org/ntsb-findings/02063015) (Personnel issues): 2 cases - [Incorrect action performance](https://openairdocs.org/ntsb-findings/02041015) (Personnel issues): 2 cases - [Cognitive overload](https://openairdocs.org/ntsb-findings/02023015) (Personnel issues): 2 cases - [Monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540) (Personnel issues): 2 cases - [Directional control](https://openairdocs.org/ntsb-findings/01062020) (Aircraft): 2 cases - [Documentation/record keeping, general](https://openairdocs.org/ntsb-findings/04033000) (Organizational issues): 1 cases - [Scheduling of personnel](https://openairdocs.org/ntsb-findings/04023010) (Organizational issues): 1 cases ## Newest cases - [NTSB CEN26LA233](https://openairdocs.org/ntsb/CEN26LA233), Jun 3, 2026: Burkhart Grob Flugzeugbau G103 Twin Astir (N4101M), Gregory, MI, substantial damage. Probable cause: The flight instructor’s improper planning during the simulated aborted launch which resulted in a touchdown on unsuitable terrain. - [NTSB WPR25LA284](https://openairdocs.org/ntsb/WPR25LA284), Sep 15, 2025: Cameron Balloons US A-225 (N980VA), Albuquerque, NM, no damage. Probable cause: The balloon pilot’s improper landing, which resulted in serious injury to a passenger. Contributing to the accident was the pilot’s failure to brief the proper landing procedure. - [NTSB DCA24LA318](https://openairdocs.org/ntsb/DCA24LA318), Sep 25, 2024: Embraer ERJ 170-100 LR (N772MR), Chicago, IL, incident, no damage. Probable cause: The flight crew’s misidentification of the intended landing runway, which resulted in an approach to and landing on the wrong runway due to their planned continuation bias. Contributing to the… - [NTSB CEN24LA181](https://openairdocs.org/ntsb/CEN24LA181), May 11, 2024: Cirrus Design SR22 (N815CD), Chesaning, MI, substantial damage. Probable cause: The pilot’s failure to maintain control while landing on a wet turf runway, which resulted in a runway excursion and impact with trees. Contributing to the accident was the pilot’s failure to ensure… - [NTSB CEN24FA064](https://openairdocs.org/ntsb/CEN24FA064), Dec 14, 2023: Pilatus PC-12/45 (N188PC), Christoval, TX, substantial damage, 2 fatal - [NTSB WPR23LA045](https://openairdocs.org/ntsb/WPR23LA045), Nov 23, 2022: Sikorsky UH-60A (N160AQ), San Diego, CA, substantial damage. Probable cause: The failure of the crewmembers of the second helicopter to maintain visual separation with the first helicopter while complying with the LC controller’s instruction to go around. Contributing to the… - [NTSB ERA23LA022](https://openairdocs.org/ntsb/ERA23LA022), Oct 17, 2022: Cessna 172S (N2476Y), Statesboro, GA, no damage, 1 fatal. Probable cause: The pilot’s failure to include deplaning procedures as part of a passenger safety briefing and failure to have the passengers remain onboard until the engine was shut down, which resulted in a… - [NTSB ERA21LA196](https://openairdocs.org/ntsb/ERA21LA196), Apr 26, 2021: Cessna 402C (N2714B), Hyannis, MA, substantial damage. Probable cause: The flight instructor’s failure to confirm the position of the left engine’s auxiliary fuel boost pump switch during a simulated engine out procedure, which resulted in an excess amount of fuel in… - [NTSB DCA19CA192](https://openairdocs.org/ntsb/DCA19CA192), Aug 6, 2019: Boeing 737 (N37437), SFO International Airport, CA, minor damage. Probable cause: the ramp controller directing a Boeing 737 to hold in a location that was marked for a regional jet. - [NTSB GAA18CA107](https://openairdocs.org/ntsb/GAA18CA107), Jan 12, 2018: Bell UH 1H (N205KS), Van Nuys, CA, substantial damage. Probable cause: The pilot’s failure to maintain clearance from a stationary helicopter during landing. Contributing to the accident was the ground crew’s failure to ensure that the helicopter would clear the… NTSB has coded findings and defining events since 2008; earlier cases used its older occurrence and cause codes and aren't counted. Findings: https://openairdocs.org/ntsb-findings.md. Defining events: https://openairdocs.org/ntsb-events.md. Phases of flight: https://openairdocs.org/ntsb-phases.md. Every investigation, filtered by finding, event, phase, state, year or model: https://openairdocs.org/ntsb.md (for example ?state=MI&fatal=1). NTSB's definitions: Accident and incident, 49 CFR 830.2 (https://www.ecfr.gov/current/title-49/subtitle-B/chapter-VIII/part-830/subpart-A/section-830.2), CICTT occurrence categories (PDF) (https://www.ntsb.gov/safety/data/Documents/datafiles/OccurrenceCategoryDefinitions.pdf), CICTT phases of flight (PDF) (https://www.ntsb.gov/safety/data/Documents/datafiles/PhaseofFlightDefinitions.pdf), and NTSB coding manual, before 2008 (PDF) (https://www.ntsb.gov/GILS/Documents/codman.pdf). NTSB publishes no definitions for its findings, only their names. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.