# Policy/procedure, general - Type: NTSB finding subsection - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Management](https://openairdocs.org/ntsb-findings/0402) › [Policy/procedure](https://openairdocs.org/ntsb-findings/040210) › Policy/procedure, general - NTSB code: 04021000 - Cases: 15 - In the probable cause: 7 - Fatal cases: 5 - All cases: https://openairdocs.org/ntsb-findings/04021000/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04021000/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04021000 ## Cases per year (in the probable cause / all) - 2008: 1 / 3 - 2009: 0 / 1 - 2010: 1 / 2 - 2012: 2 / 3 - 2014: 1 / 1 - 2015: 0 / 1 - 2018: 1 / 2 - 2019: 1 / 1 - 2020: 0 / 1 ## Defining events in these cases - [Birdstrike](https://openairdocs.org/ntsb-events/901): 1 cases - [External load event (Rotorcraft)](https://openairdocs.org/ntsb-events/480): 1 cases - [Landing area overshoot](https://openairdocs.org/ntsb-events/380): 1 cases - [Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342): 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 - [Electrical system malf/failure](https://openairdocs.org/ntsb-events/332): 1 cases - [Runway excursion](https://openairdocs.org/ntsb-events/300): 1 cases - [Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260): 1 cases - [Loss of control on ground](https://openairdocs.org/ntsb-events/230): 1 cases ## Aircraft models (registry) - [Hughes Helicopters HUGHES 369D](https://openairdocs.org/model/hughes-helicopters-hughes-369d): 2 cases - [Saab-Scania 2000](https://openairdocs.org/model/saab-scania-2000): 1 cases - [Airbus Industrie A320-214](https://openairdocs.org/model/airbus-industrie-a320-214): 1 cases - [Fairchild SA227-AC](https://openairdocs.org/model/fairchild-sa227-ac): 1 cases - [Mcdonnell Douglas MD-88](https://openairdocs.org/model/mcdonnell-douglas-md-88): 1 cases - [Cessna T210L](https://openairdocs.org/model/cessna-t210l): 1 cases - [Cessna 172S](https://openairdocs.org/model/cessna-172s): 1 cases - [Cameron Balloons US A-250](https://openairdocs.org/model/cameron-balloons-us-a-250): 1 cases - [Boeing 767-200](https://openairdocs.org/model/boeing-767-200): 1 cases - [Boeing 737-890](https://openairdocs.org/model/boeing-737-890): 1 cases ## Other findings in the same cases - [Equip certification/testing](https://openairdocs.org/ntsb-findings/04012015) (Organizational issues): 2 cases - [Installation](https://openairdocs.org/ntsb-findings/02062035) (Personnel issues): 2 cases - [Task performance, general](https://openairdocs.org/ntsb-findings/02060000) (Personnel issues): 2 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 2 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 2 cases - [Performance/control parameters, general](https://openairdocs.org/ntsb-findings/01062000) (Aircraft): 2 cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 1 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 1 cases - [Availability of policy/proc](https://openairdocs.org/ntsb-findings/04021010) (Organizational issues): 1 cases - [Equipment design](https://openairdocs.org/ntsb-findings/04011010) (Organizational issues): 1 cases ## Newest cases - [NTSB ERA20LA160](https://openairdocs.org/ntsb/ERA20LA160), Apr 25, 2020: Hughes 369 (N9159F), Pylesville, MD, substantial damage. Probable cause: The loss of engine power due to fuel starvation as a result of unporting of the fuel tank supply pickup while the helicopter was maneuvered to move a conductor wire. Contributing to the accident was… - [NTSB DCA20MA002](https://openairdocs.org/ntsb/DCA20MA002), Oct 18, 2019: Saab 2000 (N686PA), Unalaska, AK, substantial damage, 1 fatal. Probable cause: The landing gear manufacturer’s incorrect wiring of the wheel speed transducer harnesses on the left main landing gear during overhaul. The incorrect wiring caused the antiskid system not to function… - [NTSB CEN18LA309](https://openairdocs.org/ntsb/CEN18LA309), Aug 3, 2018: Cameron A 250 (N2025J), Hartsel, CO, no damage, 1 fatal. Probable cause: The passengers’ fall from the basket after landing when the basket tipped over. - [NTSB ERA18LA117](https://openairdocs.org/ntsb/ERA18LA117), Mar 28, 2018: Stanley Lancair (C-GSQQ), Sebring, FL, substantial damage. Probable cause: The failure of ground personnel to obtain permission from airport management to conduct engine test runs; adequately monitor the area behind the B737 for traffic; and install barricades to prevent… - [NTSB DCA15FA085](https://openairdocs.org/ntsb/DCA15FA085), Mar 5, 2015: Mcdonnell Douglas MD 88 (N909DL), New York, NY, substantial damage. Probable cause: the captain's inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the… - [NTSB WPR15LA025](https://openairdocs.org/ntsb/WPR15LA025), Oct 26, 2014: Cessna 172S (N353MV), Santa Monica, CA, substantial damage. Probable cause: The separation of a section of a propeller blade due to fatigue cracking. Contributing to the accident was the operator’s failure to comply with the manufacturer’s maintenance and inspection… - [NTSB CEN13FA075](https://openairdocs.org/ntsb/CEN13FA075), Nov 27, 2012: Hughes 369 (N28MP), Childress, TX, substantial damage, 1 fatal. Probable cause: The improper maintenance of the helicopter fuel system that resulted in erroneous fuel gauge indications and the pilot’s inadequate fuel management, both of which resulted in fuel exhaustion during a… - [NTSB CEN13IA059](https://openairdocs.org/ntsb/CEN13IA059), Nov 10, 2012: Fairchild SA227-AC (N619BA), Minneapolis, MN, incident, minor damage. Probable cause: Loose electrical connections to the hydraulic system and anomalies in the hydraulic shuttle valve and power pack, which resulted in an uncommanded gear unlock and collapse of the left main landing… - [NTSB OPS12IA535](https://openairdocs.org/ntsb/OPS12IA535), Apr 27, 2012: Las Vegas, NV, incident, no damage. Probable cause: Federal Aviation Administration procedures that do not ensure separation in the event of a go-around during simultaneous independent runway operations on runways that do not physically intersect but… - [NTSB ERA10GA320](https://openairdocs.org/ntsb/ERA10GA320), Jun 21, 2010: Cessna T210L (N30266), Lock Haven, PA, substantial damage, 3 fatal. Probable cause: The total loss of engine power resulting from the fatigue failure of the engine's number 2 cylinder exhaust valve. The fatigue failure was due to valve guide wear that led to excessive clearance… 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.