Culture

NTSB finding section · Organizational issues › Management

Cases
22
In the probable cause
17 (77%)
Fatal cases
13
NTSB code
040240

NTSB has coded findings and defining events since 2008. Earlier cases used its older occurrence and cause codes, so they aren’t counted here.

When and where

In green, cases where NTSB made it part of the probable cause; in gray, a factor or other finding. Findings are coded with the final report, often a year or more after the event, so the latest years are incomplete.

Cases per year

2008In the probable causeFactor only2026
Cases with Culture per year: 22 cases
20083
20092
20124
20132
20142
20151
20172
20182
20192
20221
20241
Query with SQL
duckdb -csv -c "SELECT year(c.\"eventDate\") AS year, count(DISTINCT f.case_mkey) AS cases,
    count(DISTINCT f.case_mkey) FILTER (WHERE f.\"inProbableCause\") AS in_probable_cause
  FROM 'https://openairdocs.org/data/latest/ntsb_findings.parquet' f JOIN 'https://openairdocs.org/data/latest/ntsb_case_detail.parquet' c ON c.\"mKey\" = f.case_mkey
  WHERE starts_with(f.\"findingCode\", '040240') AND c.\"eventDate\" >= DATE '2000-01-01'
  GROUP BY 1
  ORDER BY 1"

Prints the counts as CSV. It reads the release’s Parquet files over HTTPS, so there’s nothing to download first. Install DuckDB to run it.

Subsections · 4

Query with SQL
duckdb -csv -c "SELECT left(f.\"findingCode\", 8) AS code, max(f.\"tier4Name\") AS name,
    count(DISTINCT f.case_mkey) AS cases,
    count(DISTINCT f.case_mkey) FILTER (WHERE f.\"inProbableCause\") AS in_probable_cause
  FROM 'https://openairdocs.org/data/latest/ntsb_findings.parquet' f
  WHERE starts_with(f.\"findingCode\", '040240') AND f.\"findingCode\" GLOB '[0-9][0-9]*'
  GROUP BY 1
  ORDER BY cases DESC, code"

Prints the counts as CSV. It reads the release’s Parquet files over HTTPS, so there’s nothing to download first. Install DuckDB to run it.

In the same cases

Query with SQL
duckdb -csv -c "WITH matched AS (SELECT DISTINCT case_mkey, aircrafts_position FROM 'https://openairdocs.org/data/latest/ntsb_findings.parquet' WHERE starts_with(\"findingCode\", '040240'))
  SELECT * FROM (
  SELECT 'Defining event' AS kind, e.\"tier2Number\" AS code, max(e.\"eventTier2Name\") AS name, count(DISTINCT f.case_mkey) AS cases
  FROM matched f JOIN 'https://openairdocs.org/data/latest/ntsb_events.parquet' e ON e.case_mkey = f.case_mkey AND e.aircrafts_position = f.aircrafts_position AND e.\"isDefiningEvent\"
  WHERE e.\"tier2Number\" <> ''
  GROUP BY ALL
  UNION ALL
  SELECT 'Aircraft model', a.aircraft_model_code, any_value(concat_ws(' ', m.manufacturer, m.model)), count(DISTINCT f.case_mkey)
  FROM matched f JOIN 'https://openairdocs.org/data/latest/ntsb_aircrafts.parquet' a ON a.case_mkey = f.case_mkey AND a.position = f.aircrafts_position
  LEFT JOIN 'https://openairdocs.org/data/latest/faa_aircraft_model.parquet' m ON m.code = a.aircraft_model_code
  WHERE a.aircraft_model_code IS NOT NULL
  GROUP BY ALL
  UNION ALL
  SELECT 'Other finding', left(g.\"findingCode\", 8), max(g.\"tier4Name\"), count(DISTINCT g.case_mkey)
  FROM 'https://openairdocs.org/data/latest/ntsb_findings.parquet' g
  WHERE g.case_mkey IN (SELECT case_mkey FROM matched) AND NOT starts_with(g.\"findingCode\", '040240') AND g.\"findingCode\" GLOB '[0-9][0-9]*'
  GROUP BY ALL
  )
  QUALIFY row_number() OVER (PARTITION BY kind ORDER BY cases DESC) <= 10
  ORDER BY kind, cases DESC"

Prints the counts as CSV. It reads the release’s Parquet files over HTTPS, so there’s nothing to download first. Install DuckDB to run it.

Newest cases · 22

NTSB CEN24FA221Accident · 1 fatalClass 3 · FieldFinal reportAir Tractor AT502 · Whiteface, TXBoth pilot’s failure to see and avoid the other airplane during simultaneous aerial application operations over the same area. Contributing to the accident was the operator’s poor decision to assign the pilots to conduct separate aerial application operations…Jun 14, 2024 · N2032K · 2 aircraft · Substantial damageNTSB ERA23LA064Accident · No injuriesClass 3 · LimitedFinal reportBeech 95-B55 (T42A) · Athens, GAThe operator’s and the pilot’s continued operation of the airplane with a known electrical problem, resulting in a loss of electrical power and a gear-up landing.Nov 3, 2022 · N101DC · Substantial damageNTSB WPR19MA177Accident · 11 fatalClass 2 · MajorFinal reportBeech 65-A90 · Mokuleia, HIThe pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall and subsequent loss of control at an altitude that was too low for recovery. Contributing to the accident were (1) the operation of the airplane near its aft center of gravity…Jun 22, 2019 · N256TA · DestroyedNTSB CEN19FA072Accident · 3 fatalClass 1 · FieldFinal reportBell 407 · Zaleski, OHThe NTSB determines that the probable cause of this accident was Survival Flight's inadequate management of safety, which normalized pilots' and operations control specialists' noncompliance with risk analysis procedures and resulted in the initiation of the…Jan 29, 2019 · N191SF · DestroyedNTSB ERA18MA099Accident · 5 fatalClass 1 · MajorFinal reportAmerican Eurocopter AS350B2 · New York, NYLiberty Helicopters Inc.'s use of a NYONair-provided passenger harness/tether system, which caught on and activated the floor-mounted engine fuel shutoff lever and resulted in the in-flight loss of engine power and the subsequent ditching. Contributing to…Mar 11, 2018 · N350LH · Substantial damageNTSB CEN18LA119Accident · Serious injuriesClass 2 · LimitedFinal reportCzech Sport Piper Sport · Addison, TXThe operator’s use of improper fuel, which resulted in partial loss of engine power due to vapor lock.Mar 10, 2018 · N422PS · Substantial damageNTSB ANC17LA051Accident · No injuriesClass 3 · LimitedFinal reportLeonardo AW139 · Tujunga, CAA yaw excursion and uncontrolled descent due to loss of tail rotor effectiveness during aerial firefighting operations resulting in an impact with trees. A contributing factor was the pilot’s failure to maintain sufficient airspeed, coupled with a quartering…Sep 2, 2017 · N304FD · Substantial damageNTSB ANC17FA039Accident · 1 fatalClass 2 · FieldFinal reportCessna U206 · Port Alsworth, AKThe pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of visual reference and subsequent controlled flight into terrain. Contributing to the accident was (1) the inadequate preflight…Jul 27, 2017 · N1749R · DestroyedNTSB ANC15MA041Accident · 9 fatalClass 1 · MajorFinal reportDehavilland DHC-3 · Ketchikan, AK(1) the pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in his geographic disorientation and controlled flight into terrain; and (2) Promech's company culture, which tacitly endorsed flying in…Jun 25, 2015 · N270PA · Substantial damageNTSB OPS14IA007Incident · Minor injuriesIncident investigationFinal reportBoeing 757 · Powhatan, VAThe air traffic controller’s failure to provide required advisories about significant radar-observed convective precipitation along both airplanes’ flight routes and the air route traffic control center’s lack of a program to ensure that air traffic…Apr 29, 2014 · UNK · Minor damage
See all 22 cases
Query with SQL
duckdb -csv -c "SELECT c.\"ntsbNumber\", c.\"eventDate\", c.\"eventType\", c.\"eventCity\", c.\"eventStateOrRegion\", a.n_number, a.\"aircraftMake\", a.\"aircraftModel\", c.\"highestInjuryLevel\", c.\"totalFatal\", c.\"completionStatus\", c.report_url
  FROM 'https://openairdocs.org/data/latest/ntsb_case_detail.parquet' c LEFT JOIN 'https://openairdocs.org/data/latest/ntsb_aircrafts.parquet' a ON a.case_mkey = c.\"mKey\" AND a.position = 1
  WHERE c.\"mKey\" IN (SELECT f.case_mkey FROM 'https://openairdocs.org/data/latest/ntsb_findings.parquet' f WHERE starts_with(f.\"findingCode\", '040240'))
  ORDER BY c.\"eventDate\" DESC, c.\"ntsbNumber\" DESC"

Prints the whole list as CSV. It reads the release’s Parquet files over HTTPS, so there’s nothing to download first. Install DuckDB to run it.