NTSB finding section · Organizational issues › Management

Cases
17
In the probable cause
13 (76%)
Fatal cases
7
NTSB code
040250

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 Communication (organizational) per year: 17 cases
20081
20091
20101
20113
20122
20131
20142
20151
20181
20191
20231
20241
20251
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\", '040250') 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\", '040250') 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\", '040250'))
  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\", '040250') 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 · 17

NTSB DCA25MA108Accident · 67 fatalClass 1 · MajorFinal reportBombardier CL-600-2C10 · Washington, DCThe 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 available data, and their failure to act on recommendations to…Jan 30, 2025 · N709PS · 2 aircraft · DestroyedNTSB WPR24LA319Accident · No injuriesClass 3 · LimitedFinal reportBell 206L · Fern Prairie, WAAn aeroelastic interaction between the helicopter’s main rotor blades and nodal beam system, which resulted in oscillations that exceeded the design limits of the tailboom. Contributing to the accident was the failure of the main rotor blade manufacturer to…Sep 26, 2024 · N9984K · Substantial damageNTSB WPR24LA069Accident · No injuriesClass 4 · LimitedFinal reportTaylorcraft BC12-D · Whitefish, MTThe failure of the airport authorities to renew the airport closure NOTAM for the airport. Contributing to the accident, was the pilot’s inability to see the runway closure sign.Dec 23, 2023 · N43415 · Substantial damageNTSB ANC19FA019Accident · 2 fatalClass 2 · FieldFinal reportDe Havilland DHC 2 · Metlakatla, AKThe pilot’s inadequate compensation for a quartering tailwind during a water landing, which resulted in a loss of control and subsequent nose-over. Contributing to the accident was the company’s inadequate operational control of the flight release process,…May 20, 2019 · N67667 · Substantial damageNTSB GAA18CA424Accident · No injuriesData collectionFinal reportBell 206 · New Castle, INThe pilot's failure to ensure that the fill hose was disconnected from the helicopter before takeoff, which resulted in the fill hose striking the tail rotor and the subsequent loss of tail rotor effectiveness. Contributing to the accident was inadequate…Jul 16, 2018 · N39LR · Substantial damageNTSB GAA15CA128Accident · No injuriesData collectionFinal reportBeech C23 · Long Beach, CAThe pilot failed to maintain clearance from trees while maneuvering to land at night, which resulted in a collision with terrain/objects. A factor contributing to the accident was the lack of oversight by ATC; failing to insure that the fully operational VASI…Jun 19, 2015 · N24022 · Substantial damageNTSB ENG14IA018Incident · No injuriesIncident investigationFinal reportPiper PA46 500TP · Denver, COThe pilots' incorrect activation of the Manual Override Lever, during ground operation, in an attempt to correct a sub-idle speed condition of the engine, resulting in an over-temperature of the CT blades, their subsequent distress and failure of the engine.…Jul 7, 2014 · N406CD · Minor damageNTSB ERA14FA464Accident · 1 fatalField investigationFinal reportFortuna Dave Sonex · Dunnellon, FLThe in-flight collision with a tree in a heavily wooded area during controlled flight while the pilot was attempting a forced landing for reasons that could not be determined based on the available evidence. Contributing to the delay in locating the wreckage…Apr 5, 2014 · N229P · Substantial damageNTSB ERA13LA188Accident · No injuriesLimited investigationFinal reportCessna 402C · Fort Lauderdale, FLThe disconnection of the nose landing gear actuator, which resulted in the subsequent collapse of the nose landing gear. Contributing to the accident was the repair station’s inadequate maintenance, postmaintenance inspection process, and oversight of the…Apr 1, 2013 · VQ-TIN · Substantial damageNTSB WPR13IA020Incident · No injuriesIncident investigationFinal reportAgusta A119 · Dolan Springs, AZInsufficient clearance between a truck and the main rotor blades of a helicopter on the ground with the engine running because of the lack of on-scene coordination between the agencies that responded to and were tasked with managing the vehicle accident site.Oct 20, 2012 · N207CF · Minor damage
See all 17 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\", '040250'))
  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.