# Design of document/info - Type: NTSB finding subsection - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Development](https://openairdocs.org/ntsb-findings/0401) › [Design](https://openairdocs.org/ntsb-findings/040110) › Design of document/info - NTSB code: 04011020 - Cases: 11 - In the probable cause: 7 - Fatal cases: 1 - All cases: https://openairdocs.org/ntsb-findings/04011020/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04011020/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04011020 ## Cases per year (in the probable cause / all) - 2009: 1 / 1 - 2010: 2 / 3 - 2011: 1 / 3 - 2012: 1 / 1 - 2013: 0 / 1 - 2015: 1 / 1 - 2019: 1 / 1 ## Defining events in these cases - [Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330): 3 cases - [Fuel exhaustion](https://openairdocs.org/ntsb-events/192): 2 cases - [Collision during takeoff/land](https://openairdocs.org/ntsb-events/490): 1 cases - [Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340): 1 cases - [Runway excursion](https://openairdocs.org/ntsb-events/300): 1 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 1 cases - [Ground collision](https://openairdocs.org/ntsb-events/200): 1 cases - [Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150): 1 cases ## Aircraft models (registry) - [Mitsubishi MU-2B-25](https://openairdocs.org/model/mitsubishi-mu-2b-25): 1 cases - [Airbus Industrie A319-131](https://openairdocs.org/model/airbus-industrie-a319-131): 1 cases - [Mcdonnell Douglas MD-11F](https://openairdocs.org/model/mcdonnell-douglas-md-11f): 1 cases - [Cessna 560XL](https://openairdocs.org/model/cessna-560xl): 1 cases - [Cessna 172M](https://openairdocs.org/model/cessna-172m): 1 cases - [Bombardier CL-600-2C11](https://openairdocs.org/model/bombardier-cl-600-2c11): 1 cases - [Boeing 757-232](https://openairdocs.org/model/boeing-757-232): 1 cases - [American Eurocopter AS350B3](https://openairdocs.org/model/american-eurocopter-as350b3): 1 cases - [Evolution Trikes REVO](https://openairdocs.org/model/evolution-trikes-revo): 1 cases - [Flight Design CTSW](https://openairdocs.org/model/flight-design-ctsw): 1 cases ## Other findings in the same cases - [Use of equip/system](https://openairdocs.org/ntsb-findings/02063015) (Personnel issues): 3 cases - [Equipment design](https://openairdocs.org/ntsb-findings/04011010) (Organizational issues): 2 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 2 cases - [Forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035) (Personnel issues): 2 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 2 cases - [Fuel system, general](https://openairdocs.org/ntsb-findings/01022800) (Aircraft): 2 cases - [Equipment manufacture](https://openairdocs.org/ntsb-findings/04013010) (Organizational issues): 1 cases - [Selection/certification/testing, general](https://openairdocs.org/ntsb-findings/04012000) (Organizational issues): 1 cases - [Tailwind](https://openairdocs.org/ntsb-findings/03034015) (Environmental issues): 1 cases - [Runway/landing area condition](https://openairdocs.org/ntsb-findings/03017035) (Environmental issues): 1 cases ## Newest cases - [NTSB WPR19FA230](https://openairdocs.org/ntsb/WPR19FA230), Aug 21, 2019: Cessna 560XL (N91GY), Oroville, CA, destroyed. Probable cause: The pilot’s failure to release the parking brake before attempting to initiate the takeoff, which produced an unexpected retarding force and airplane nose down pitching moment. Also causal was the… - [NTSB CEN15MA290](https://openairdocs.org/ntsb/CEN15MA290), Jul 3, 2015: Airbus Helicopters AS350B3E (N390LG), Frisco, CO, destroyed, 1 fatal. Probable cause: Airbus Helicopters' dual-hydraulic AS350 B3e helicopter's (1) preflight hydraulic check, which depleted hydraulic pressure in the tail rotor hydraulic circuit, and (2) lack of salient alerting to the… - [NTSB WPR13LA396](https://openairdocs.org/ntsb/WPR13LA396), Sep 2, 2013: Flight Design Ctsw (N102HA), Sisters, OR, substantial damage. Probable cause: The pilot's inadequate preflight fuel planning and poor decision-making, which resulted in fuel exhaustion and the subsequent loss of engine power. Contributing to the accident was the lack of… - [NTSB DCA13CA035](https://openairdocs.org/ntsb/DCA13CA035), Dec 26, 2012: Mcdonnell Douglas MD-11F (N612FE), Memphis, TN, substantial damage. Probable cause: the operator's failure to provide appropriate training and documentation for ground personnel, leading the marshaller to inadvertently guide the airplane into the collision. - [NTSB ENG12IA004](https://openairdocs.org/ntsb/ENG12IA004), Oct 23, 2011: Bombardier CL600 2C10 (N751EV), Atlanta, GA, incident, no damage. Probable cause: The Start Operability Bleed Valve (OBV) fuel return adapter-fitting fractured and separated in cyclic fatigue, which allowed fuel to spill onto a hot engine case that ignited the undercowl fire. The… - [NTSB ERA11LA507](https://openairdocs.org/ntsb/ERA11LA507), Sep 28, 2011: Mitsubishi MU-2B-25 (N344KL), Atlanta, GA, substantial damage. Probable cause: The improper installation of the nose landing gear strut and subsequent collapse of the nose landing gear during landing. - [NTSB ENG11IA035](https://openairdocs.org/ntsb/ENG11IA035), Jun 21, 2011: Boeing 757-232 (N6714Q), Atlanta, GA, incident, no damage. Probable cause: Fuel leaking from the fuel flow transmitter that ignited on contact with the engine’s hot cases which resulted in an engine undercowl fire. The fuel leak resulted from the fuel flow transmitter end… - [NTSB WPR10FA384](https://openairdocs.org/ntsb/WPR10FA384), Aug 6, 2010: Cessna 172 (N9730H), Roche Harbor, WA, substantial damage. Probable cause: The pilot’s failure to attain an adequate climb airspeed due to his use of flaps for takeoff, and his selection of a runway, which resulted in an uphill, and possibly downwind, takeoff and subsequent… - [NTSB WPR10CA224](https://openairdocs.org/ntsb/WPR10CA224), Apr 19, 2010: Evolution Trikes Revo (N98EV), Eleele, HI, substantial damage. Probable cause: A loss of engine power as a result of fuel exhaustion due to the pilot's improper decision to continue the flight after the low fuel warning. Contributing to the accident was the typographical error… - [NTSB DCA10IA021](https://openairdocs.org/ntsb/DCA10IA021), Jan 10, 2010: Airbus Industrie A319-131 (N816UA), Newark, NJ, incident, minor damage. Probable cause: A mechanical failure of internal components of the right main landing gear door actuator resulting in the flight crew being unable to fully extend the right main landing gear using the normal and… 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.