# Policy/procedure development - 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) › Policy/procedure development - NTSB code: 04011025 - Cases: 17 - In the probable cause: 15 - Fatal cases: 4 - All cases: https://openairdocs.org/ntsb-findings/04011025/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04011025/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04011025 ## Cases per year (in the probable cause / all) - 2008: 1 / 1 - 2009: 2 / 2 - 2011: 2 / 2 - 2012: 3 / 3 - 2013: 1 / 1 - 2014: 0 / 1 - 2016: 2 / 2 - 2017: 1 / 2 - 2020: 1 / 1 - 2024: 1 / 1 - 2025: 1 / 1 ## Defining events in these cases - [Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330): 3 cases - [Midair collision](https://openairdocs.org/ntsb-events/250): 2 cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 1 cases - [Loss of engine power (total)](https://openairdocs.org/ntsb-events/341): 1 cases - [Part(s) separation from AC](https://openairdocs.org/ntsb-events/338): 1 cases - [Aircraft structural failure](https://openairdocs.org/ntsb-events/337): 1 cases - [Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241): 1 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 1 cases - [Fuel contamination](https://openairdocs.org/ntsb-events/193): 1 cases - [Fuel exhaustion](https://openairdocs.org/ntsb-events/192): 1 cases ## Aircraft models (registry) - [Aerospatiale AS350BA](https://openairdocs.org/model/aerospatiale-as350ba): 1 cases - [Schweizer G-164B](https://openairdocs.org/model/schweizer-g-164b): 1 cases - [Robinson Helicopter R44 II](https://openairdocs.org/model/robinson-helicopter-r44-ii): 1 cases - [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161): 1 cases - [Gulfstream Aerospace GVI](https://openairdocs.org/model/gulfstream-aerospace-gvi): 1 cases - [Dehavilland DHC-6 TWIN OTTER](https://openairdocs.org/model/dehavilland-dhc-6-twin-otter): 1 cases - [Cessna 172R](https://openairdocs.org/model/cessna-172r): 1 cases - [Bombardier DHC-8-402](https://openairdocs.org/model/bombardier-dhc-8-402): 1 cases - [Bombardier CL-600-2C10](https://openairdocs.org/model/bombardier-cl-600-2c10): 1 cases - [Bell Helicopter Textron 525](https://openairdocs.org/model/bell-helicopter-textron-525): 1 cases ## Other findings in the same cases - [Use of equip/system](https://openairdocs.org/ntsb-findings/02063015) (Personnel issues): 5 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 3 cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 2 cases - [Between groups/organizations](https://openairdocs.org/ntsb-findings/04025020) (Organizational issues): 2 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 2 cases - [Equip certification/testing](https://openairdocs.org/ntsb-findings/04012015) (Organizational issues): 2 cases - [Terrain, general](https://openairdocs.org/ntsb-findings/03021000) (Environmental issues): 2 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 2 cases - [Lack of action](https://openairdocs.org/ntsb-findings/02041030) (Personnel issues): 2 cases - [Airspeed](https://openairdocs.org/ntsb-findings/01062010) (Aircraft): 2 cases ## Newest cases - [NTSB DCA25MA108](https://openairdocs.org/ntsb/DCA25MA108), Jan 30, 2025: Bombardier CL-600-2C10 (N709PS), Washington, DC, destroyed, 67 fatal. Probable cause: The Federal Aviation Administration’s (FAA) placement of a helicopter route in close proximity to a runway approach path; their failure to regularly review and evaluate helicopter routes and… - [NTSB ERA24LA216](https://openairdocs.org/ntsb/ERA24LA216), Feb 20, 2024: Apellix B1 Washing Drone (FA33N7WLTR), Orlando, FL, substantial damage. Probable cause: A failure of the sUAS’s magnetometer while operating in close proximity to commercial air conditioning equipment, which resulted in the sUAS’s erratic maneuvering. Contributing to the accident was… - [NTSB DCA20IA081](https://openairdocs.org/ntsb/DCA20IA081), Feb 6, 2020: Aerospatiale AS350BA (N611TC), Johnson Valley, CA, incident, minor damage. Probable cause: the failure of the small UAS remote pilot to give way to the helicopter, resulting in an inflight collision. Contributing to the incident was the sUAS remote pilot’s failure to assess and mitigate… - [NTSB WPR17LA159](https://openairdocs.org/ntsb/WPR17LA159), Jul 21, 2017: Robinson Helicopter R44 II (N3254E), Van Nuys, CA, substantial damage. Probable cause: An improper repair of the right magneto's tachometer and governor signal wire, which failed during cruise flight and initiated a simultaneous malfunction of both the engine tachometer and governor… - [NTSB CEN17LA264](https://openairdocs.org/ntsb/CEN17LA264), Jul 6, 2017: Bell 47D1 (N153B), Big Lake, MN, substantial damage. Probable cause: The failure of the metal core assembly within a wooden main rotor blade due to undetected corrosion and fatigue, which caused the wooden blade to separate from the rotor mast. - [NTSB GAA16CA442](https://openairdocs.org/ntsb/GAA16CA442), Aug 20, 2016: Cessna 172 (N35408), Anchorage, AK, substantial damage. Probable cause: The facility's designation of the taxiway for use by maintenance personnel to conduct high thrust tests without appropriate safeguards in place, which led to maintenance personnel conducting… - [NTSB DCA16FA199](https://openairdocs.org/ntsb/DCA16FA199), Jul 6, 2016: Bell 525 (N525TA), Italy, TX, destroyed, 2 fatal. Probable cause: A severe vibration of the helicopter that led to the crew's inability to maintain sufficient rotor rotation speed (Nr), leading to excessive main rotor blade flapping, subsequent main rotor blade… - [NTSB WPR14LA201](https://openairdocs.org/ntsb/WPR14LA201), May 13, 2014: Schweizer G 164B (N3633C), Biggs, CA, substantial damage. Probable cause: The assembler’s improper fabrication of a fuel line (hose) and the subsequent failure to verify that it was not occluded, which resulted in fuel starvation and a total loss of engine power during… - [NTSB CEN13LA283](https://openairdocs.org/ntsb/CEN13LA283), May 9, 2013: Air Tractor AT-302 (N3650B), Winnie, TX, substantial damage. Probable cause: The improper decision by the pilot to attempt a flight with a known fuel system-related maintenance discrepancy, which resulted in a fuel imbalance and subsequent fuel starvation during an approach… - [NTSB ERA13LA065](https://openairdocs.org/ntsb/ERA13LA065), Nov 20, 2012: Beech C90A (N702DK), Roanoke, VA, substantial damage. Probable cause: The failure of the right main landing gear bearing actuator support brackets. Contributing to the accident was the owner's and operator's failure to comply with the airplane manufacturer's mandatory… 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.