# Safety - Type: NTSB finding subsection - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Management](https://openairdocs.org/ntsb-findings/0402) › [Culture](https://openairdocs.org/ntsb-findings/040240) › Safety - NTSB code: 04024010 - Cases: 11 - In the probable cause: 8 - Fatal cases: 8 - All cases: https://openairdocs.org/ntsb-findings/04024010/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04024010/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04024010 ## Cases per year (in the probable cause / all) - 2009: 1 / 1 - 2012: 1 / 1 - 2013: 2 / 2 - 2015: 1 / 1 - 2017: 1 / 1 - 2018: 1 / 2 - 2019: 1 / 2 - 2024: 0 / 1 ## Defining events in these cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 2 cases - [Air traffic event](https://openairdocs.org/ntsb-events/100): 2 cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 1 cases - [Abrupt maneuver](https://openairdocs.org/ntsb-events/270): 1 cases - [Midair collision](https://openairdocs.org/ntsb-events/250): 1 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 1 cases - [Fuel related](https://openairdocs.org/ntsb-events/190): 1 cases - [Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120): 1 cases - [Unknown or undetermined](https://openairdocs.org/ntsb-events/000): 1 cases ## Aircraft models (registry) - [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3): 1 cases - [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300): 1 cases - [Dehavilland DHC-3](https://openairdocs.org/model/dehavilland-dhc-3): 1 cases - [Cessna U206G](https://openairdocs.org/model/cessna-u206g): 1 cases - [Bell 407](https://openairdocs.org/model/bell-407): 1 cases - [Beech 65-A90](https://openairdocs.org/model/beech-65-a90): 1 cases - [American Eurocopter AS350B2](https://openairdocs.org/model/american-eurocopter-as350b2): 1 cases - [Czech Sport PIPER SPORT](https://openairdocs.org/model/czech-sport-piper-sport): 1 cases - [Air Tractor AT-502B](https://openairdocs.org/model/air-tractor-at-502b): 1 cases - [Agusta A109E](https://openairdocs.org/model/agusta-a109e): 1 cases ## Other findings in the same cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 7 cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 6 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 6 cases - [Adherence to safety program](https://openairdocs.org/ntsb-findings/04035020) (Organizational issues): 2 cases - [Pressures/demands](https://openairdocs.org/ntsb-findings/04024020) (Organizational issues): 2 cases - [Standard operating practices](https://openairdocs.org/ntsb-findings/04024015) (Organizational issues): 2 cases - [Adequacy of documents/info](https://openairdocs.org/ntsb-findings/04022045) (Organizational issues): 2 cases - [Below VFR minima](https://openairdocs.org/ntsb-findings/03035075) (Environmental issues): 2 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 2 cases - [Weather planning](https://openairdocs.org/ntsb-findings/02061020) (Personnel issues): 2 cases ## Newest cases - [NTSB CEN24FA221](https://openairdocs.org/ntsb/CEN24FA221), Jun 14, 2024: Air Tractor AT502 (N2032K), Whiteface, TX, substantial damage, 1 fatal. Probable cause: Both 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… - [NTSB WPR19MA177](https://openairdocs.org/ntsb/WPR19MA177), Jun 22, 2019: Beech 65-A90 (N256TA), Mokuleia, HI, destroyed, 11 fatal. Probable cause: The 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… - [NTSB CEN19FA072](https://openairdocs.org/ntsb/CEN19FA072), Jan 29, 2019: Bell 407 (N191SF), Zaleski, OH, destroyed, 3 fatal. Probable cause: The 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… - [NTSB ERA18MA099](https://openairdocs.org/ntsb/ERA18MA099), Mar 11, 2018: American Eurocopter AS350B2 (N350LH), New York, NY, substantial damage, 5 fatal. Probable cause: Liberty 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… - [NTSB CEN18LA119](https://openairdocs.org/ntsb/CEN18LA119), Mar 10, 2018: Czech Sport Piper Sport (N422PS), Addison, TX, substantial damage. Probable cause: The operator’s use of improper fuel, which resulted in partial loss of engine power due to vapor lock. - [NTSB ANC17FA039](https://openairdocs.org/ntsb/ANC17FA039), Jul 27, 2017: Cessna U206 (N1749R), Port Alsworth, AK, destroyed, 1 fatal. Probable cause: The 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.… - [NTSB ANC15MA041](https://openairdocs.org/ntsb/ANC15MA041), Jun 25, 2015: Dehavilland DHC-3 (N270PA), Ketchikan, AK, substantial damage, 9 fatal. Probable cause: (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)… - [NTSB OPS13IA071](https://openairdocs.org/ntsb/OPS13IA071), Jul 5, 2013: Gulfstream GIV - Undesignat (N0), Las Vegas, NV, incident, no damage. Probable cause: The Federal Aviation Administration's (FAA) inadequate procedures, which did not require specific separation between aircraft operating on nonintersecting runways where flightpaths may intersect and… - [NTSB ANC13GA036](https://openairdocs.org/ntsb/ANC13GA036), Mar 31, 2013: Eurocopter AS350 (N911AA), Talkeetna, AK, destroyed, 3 fatal. Probable cause: The pilot's decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot's spatial disorientation and loss of control. Also causal was the… - [NTSB ERA13LA042](https://openairdocs.org/ntsb/ERA13LA042), Oct 28, 2012: Piper PA-32R-300 (N4478F), Sevierville, TN, substantial damage. Probable cause: The air traffic controller’s failure to comply with the required vectoring and safety alert procedures, which resulted in the airplane’s flight into rising terrain. Contributing to the accident was… 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.