# Standard operating practices - 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) › Standard operating practices - NTSB code: 04024015 - Cases: 10 - In the probable cause: 8 - Fatal cases: 6 - All cases: https://openairdocs.org/ntsb-findings/04024015/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04024015/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04024015 ## Cases per year (in the probable cause / all) - 2008: 2 / 2 - 2009: 1 / 1 - 2012: 1 / 2 - 2014: 1 / 2 - 2015: 1 / 1 - 2017: 1 / 1 - 2019: 1 / 1 ## Defining events in these cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 2 cases - [Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120): 2 cases - [Collision during takeoff/land](https://openairdocs.org/ntsb-events/490): 1 cases - [Turbulence encounter](https://openairdocs.org/ntsb-events/360): 1 cases - [Low altitude operation/event](https://openairdocs.org/ntsb-events/220): 1 cases - [Fuel related](https://openairdocs.org/ntsb-events/190): 1 cases - [AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081): 1 cases - [Unknown or undetermined](https://openairdocs.org/ntsb-events/000): 1 cases ## Aircraft models (registry) - [Sikorsky S-61N](https://openairdocs.org/model/sikorsky-s-61n): 1 cases - [Raytheon 1900D](https://openairdocs.org/model/raytheon-1900d): 1 cases - [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181): 1 cases - [Hawker HAWKER HUNTER MK.58A](https://openairdocs.org/model/hawker-hawker-hunter-mk-58a): 1 cases - [Dehavilland DHC-3](https://openairdocs.org/model/dehavilland-dhc-3): 1 cases - [Cessna 210E](https://openairdocs.org/model/cessna-210e): 1 cases - [Cessna 182B](https://openairdocs.org/model/cessna-182b): 1 cases - [Bell 407](https://openairdocs.org/model/bell-407): 1 cases - [Agustawestland Philadelphia AW139](https://openairdocs.org/model/agustawestland-philadelphia-aw139): 1 cases ## Other findings in the same cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 5 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 5 cases - [Lack of action](https://openairdocs.org/ntsb-findings/02041030) (Personnel issues): 3 cases - [Altitude](https://openairdocs.org/ntsb-findings/01062012) (Aircraft): 3 cases - [Safety](https://openairdocs.org/ntsb-findings/04024010) (Organizational issues): 2 cases - [Use of equip/system](https://openairdocs.org/ntsb-findings/02063015) (Personnel issues): 2 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 2 cases - [Navigation system, general](https://openairdocs.org/ntsb-findings/01023400) (Aircraft): 2 cases - [Adherence to safety program](https://openairdocs.org/ntsb-findings/04035020) (Organizational issues): 1 cases - [Adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015) (Organizational issues): 1 cases ## Newest cases - [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 ANC17LA051](https://openairdocs.org/ntsb/ANC17LA051), Sep 2, 2017: Leonardo AW139 (N304FD), Tujunga, CA, substantial damage. Probable cause: A 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… - [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 OPS14IA007](https://openairdocs.org/ntsb/OPS14IA007), Apr 29, 2014: Boeing 757 (UNK), Powhatan, VA, incident, minor damage. Probable cause: The 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… - [NTSB CEN14GA135](https://openairdocs.org/ntsb/CEN14GA135), Jan 31, 2014: Cessna 210E (N4957U), Oden, AR, substantial damage, 1 fatal. Probable cause: The pilot’s improper decision to fly into an area with reported marginal meteorological conditions in an airplane not maintained for instrument flight and his subsequent failure to maintain clearance… - [NTSB WPR12FA420](https://openairdocs.org/ntsb/WPR12FA420), Sep 13, 2012: Piper PA-28-181 (N4188E), Strawberry, AZ, substantial damage, 3 fatal. Probable cause: The flight instructor's and the evaluator's failure to divert at an appropriate time during cruise flight, which resulted in the airplane's inability to maintain a sufficient altitude to clear rising… - [NTSB DCA12FA076](https://openairdocs.org/ntsb/DCA12FA076), May 18, 2012: Hawker Hawker Hunter MK.58A (N329AX), Point Mugu, CA, destroyed, 1 fatal. Probable cause: the pilot's decision to continue the flight with a known fuel imbalance condition that resulted in a loss of lateral control when the imbalance exceeded the known capabilities of the airplane. The… - [NTSB CEN09LA525](https://openairdocs.org/ntsb/CEN09LA525), Aug 15, 2009: Cessna 182 (N2364G), Caddo Mills, TX, minor damage. Probable cause: The failure of the operator to ensure that the airplane engine was shutdown during passenger unloading and the lack of adequate supervision of the passenger by the pilot and ground crewmember. - [NTSB LAX08PA259](https://openairdocs.org/ntsb/LAX08PA259), Aug 6, 2008: Sikorsky S-61N (N612AZ), Weaverville, CA, destroyed, 9 fatal. Probable cause: The following actions by Carson Helicopters: 1) the intentional understatement of the helicopter's empty weight, 2) the alteration of the power available chart to exaggerate the helicopter's lift… - [NTSB SEA08IA096](https://openairdocs.org/ntsb/SEA08IA096), Mar 26, 2008: Raytheon 1900D (N261GL), Page, AZ, incident, minor damage. Probable cause: The flight crew’s unprofessional behavior and deviation from standard operating procedures which resulted in an in-flight emergency. 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.