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NTSB finding · Organizational issues › Support/oversight/monitoring › Training

All 26 cases19 in the probable cause
Cases
26
In the probable cause
19 (73%)
Fatal cases
11
NTSB code
04031000

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

Where

Open the map
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\", '04031000') 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.

In the same cases

Defining events
Aircraft models

Aircraft matched to the registry by N-number and date.

Other findings
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\", '04031000'))
  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\", '04031000') 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 · 26

NTSB DCA24MA063Accident · Minor injuriesClass 1 · MajorFinal reportBoeing 737-9 · Portland, ORthe in-flight separation of the left mid exit door (MED) plug due to Boeing Commercial Airplanes’ failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its…Jan 6, 2024 · N704AL · Substantial damageNTSB ANC23FA008Accident · 3 fatalClass 3 · FieldFinal reportRaytheon C90A · Kaupo, HIGuardian Flight’s inadequate pilot training and performance tracking, which failed to identify and correct the pilot’s consistent lack of skill, and which resulted in the pilot’s inability to maintain his position inflight using secondary instruments to…Dec 15, 2022 · N13GZ · Substantial damageNTSB DCA22MA009Accident · Serious injuriesClass 2 · MajorFinal reportMcdonnell Douglas DC-9-87 (MD-87) · Brookshire, TXThe jammed condition of both elevators, which resulted from exposure to localized, dynamic high wind while the airplane was parked and prevented the airplane from rotating during the takeoff roll. Also causal was the failure of Everts Air Cargo, the pilots’…Oct 19, 2021 · N987AK · DestroyedNTSB DCA19IA036Incident · No injuriesClass 3 · IncidentFinal reportBoeing 737 · Burbank, CA(1) The flight crewmembers’ decision, due to plan continuation bias, to continue the approach despite indications of windshear and a higher-than-expected tailwind and (2) the flight crew’s misperception of the airplane’s touchdown point, which was farther…Dec 6, 2018 · N752SW · Minor damageNTSB WPR19IA030Incident · Minor injuriesClass 3 · IncidentFinal reportCessna 208 · Bakersfield, CAThe pilot's loss of consciousness while taxiing due to an accumulation of toxic levels of carbon dioxide gas inside the airplane as a result of dry ice sublimation. Also causal was the pilot's decision to fly the airplane in an unventilated configuration, the…Nov 24, 2018 · N781FE · No damageNTSB CEN18FA259Accident · Serious injuriesField investigationFinal reportEurocopter Deutschland EC135 P1 · Chicago, ILThe pilot's inadvertent disabling of the No. 1 and No. 2 engines' electronic engine control systems, which resulted in engine and rotor overspeed conditions, a subsequent autorotation, and a hard landing. Contributing to the accident were the pilot's…Jul 8, 2018 · N312SA · Substantial damageNTSB CEN18FA063Accident · 12 fatalField investigationFinal reportCessna 208 · Punta Islita, Costa RicaThe flight crew's failure to maintain airspeed while maneuvering to exit an area of rising terrain, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall. Contributing to the accident was the flight crew's…Dec 31, 2017 · TI-BEI · DestroyedNTSB CEN17LA078Accident · Serious injuriesLimited investigationFinal reportTextron 525C · Howell, MIThe pilot's attempted landing on the ice-covered runway, which resulted in a runway excursion and impact with terrain. Contributing to the accident was airport personnel's lack of training regarding issuance of NOTAMsJan 16, 2017 · N525PZ · Substantial damageNTSB ANC17MA001Accident · 3 fatalClass 1 · MajorFinal reportCessna 208B · Togiak, AKThe flight crew's decision to continue the visual flight rules flight into deteriorating visibility and their failure to perform an immediate escape maneuver after entry into instrument meteorological conditions, which resulted in controlled flight into…Oct 2, 2016 · N208SD · DestroyedNTSB ANC15FA049Accident · 1 fatalClass 3 · FieldFinal reportCessna 207A · Juneau, AKThe pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its…Jul 17, 2015 · N62AK · Substantial damage
See all 26 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\", '04031000'))
  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.