# Oversight - Type: NTSB finding section - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Support/oversight/monitoring](https://openairdocs.org/ntsb-findings/0403) › Oversight - NTSB code: 040320 - Cases: 135 - In the probable cause: 96 - Fatal cases: 71 - All cases: https://openairdocs.org/ntsb-findings/040320/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/040320/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/040320 ## Cases per year (in the probable cause / all) - 2008: 6 / 8 - 2009: 3 / 7 - 2010: 6 / 11 - 2011: 9 / 10 - 2012: 6 / 9 - 2013: 12 / 14 - 2014: 7 / 8 - 2015: 11 / 15 - 2016: 7 / 7 - 2017: 7 / 9 - 2018: 3 / 4 - 2019: 4 / 5 - 2020: 1 / 2 - 2021: 2 / 4 - 2022: 5 / 8 - 2023: 3 / 6 - 2024: 2 / 5 - 2025: 2 / 3 ## Findings - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015): 61 cases, 43 in the probable cause - [Oversight of maintenance](https://openairdocs.org/ntsb-findings/04032020): 28 cases, 21 in the probable cause - [Oversight of personnel](https://openairdocs.org/ntsb-findings/04032010): 26 cases, 21 in the probable cause - [Oversight of reg compliance](https://openairdocs.org/ntsb-findings/04032040): 14 cases, 10 in the probable cause - [Oversight, general](https://openairdocs.org/ntsb-findings/04032000): 7 cases, 5 in the probable cause - [Equipment monitoring](https://openairdocs.org/ntsb-findings/04032025): 7 cases, 5 in the probable cause - [Parts/tools tracking](https://openairdocs.org/ntsb-findings/04032030): 2 cases, 1 in the probable cause - [Document revision tracking](https://openairdocs.org/ntsb-findings/04032035): 2 cases, 1 in the probable cause ## Defining events in these cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 16 cases - [Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120): 12 cases - [Loss of engine power (total)](https://openairdocs.org/ntsb-events/341): 8 cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 7 cases - [Collision during takeoff/land](https://openairdocs.org/ntsb-events/490): 5 cases - [Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340): 5 cases - [Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330): 5 cases - [Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241): 5 cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 4 cases - [Part(s) separation from AC](https://openairdocs.org/ntsb-events/338): 4 cases ## Aircraft models (registry) - [Eurocopter AS 350 B2](https://openairdocs.org/model/eurocopter-as-350-b2): 4 cases - [Dehavilland DHC-3](https://openairdocs.org/model/dehavilland-dhc-3): 4 cases - [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3): 3 cases - [Sikorsky S-61N](https://openairdocs.org/model/sikorsky-s-61n): 2 cases - [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300): 2 cases - [Eurocopter Deutschland MBB-BK 117 C-2](https://openairdocs.org/model/eurocopter-deutschland-mbb-bk-117-c-2): 2 cases - [Cessna 208B](https://openairdocs.org/model/cessna-208b): 2 cases - [Boeing B-17G](https://openairdocs.org/model/boeing-b-17g): 2 cases - [Bell 407](https://openairdocs.org/model/bell-407): 2 cases - [Bell 206B](https://openairdocs.org/model/bell-206b): 2 cases ## Other findings in the same cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 34 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 24 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 22 cases - [Scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010) (Personnel issues): 12 cases - [Performance/control parameters, general](https://openairdocs.org/ntsb-findings/01062000) (Aircraft): 12 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 11 cases - [Adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015) (Organizational issues): 10 cases - [Incorrect action performance](https://openairdocs.org/ntsb-findings/02041015) (Personnel issues): 10 cases - [Incorrect action selection](https://openairdocs.org/ntsb-findings/02041010) (Personnel issues): 10 cases - [Airspeed](https://openairdocs.org/ntsb-findings/01062010) (Aircraft): 10 cases ## Newest cases - [NTSB ANC25MA018](https://openairdocs.org/ntsb/ANC25MA018), Feb 6, 2025: Textron 208B (N321BA), Nome, AK, destroyed, 10 fatal. Probable cause: The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s inadequate airspeed management due to workload and degraded situation awareness and his… - [NTSB WPR25LA089](https://openairdocs.org/ntsb/WPR25LA089), Feb 1, 2025: Lockheed C-130A (N466TM), Daggett, CA, no damage. Probable cause: An inflight upset due to an improperly secured load that resulted in serious injuries. - [NTSB DCA25MA108](https://openairdocs.org/ntsb/DCA25MA108), Jan 30, 2025: Bombardier CL-600-2C10 (N709PS), Washington, DC, destroyed, 67 fatal. Probable cause: The 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… - [NTSB ANC24FA102](https://openairdocs.org/ntsb/ANC24FA102), Sep 24, 2024: Cessna 206 (N8255Q), Chalkyitsik, AK, substantial damage, 1 fatal. Probable cause: A loss of engine power due to water-contaminated fuel as a result of the pilot’s inadequate preflight inspection. Contributing to the accident was the operator’s failure to ensure replacement filters… - [NTSB WPR24LA241](https://openairdocs.org/ntsb/WPR24LA241), Jul 13, 2024: Robinson Helicopter R44 II (N6960), Herriman, UT, substantial damage. Probable cause: A hard landing following a total loss of engine power due to fuel starvation as a result of the improper idle setting of the helicopter’s engine. Contributing to the loss of engine power was the… - [NTSB CEN24LA144](https://openairdocs.org/ntsb/CEN24LA144), Apr 1, 2024: Piper PA28 (N8438B), Muncie, IN, destroyed, 1 fatal. Probable cause: The pilot’s spatial disorientation and subsequent loss of control while maneuvering outside established instrument approach procedures in instrument meteorological conditions, which resulted in an… - [NTSB WPR24FA080](https://openairdocs.org/ntsb/WPR24FA080), Jan 30, 2024: Swanson R/Swanson S RV-6 (N30AK), Concord, CA, substantial damage, 1 fatal. Probable cause: A total loss of engine power during takeoff due to a separated fuel line and the pilot’s subsequent failure to maintain control of the airplane. Contributing to the accident were the pilot's medical… - [NTSB DCA24MA063](https://openairdocs.org/ntsb/DCA24MA063), Jan 6, 2024: Boeing 737-9 (N704AL), Portland, OR, substantial damage. Probable cause: the 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… - [NTSB WPR24LA069](https://openairdocs.org/ntsb/WPR24LA069), Dec 23, 2023: Taylorcraft BC12-D (N43415), Whitefish, MT, substantial damage. Probable cause: The 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. - [NTSB WPR24FA018](https://openairdocs.org/ntsb/WPR24FA018), Oct 21, 2023: Beech A36 (N8248K), Covelo, CA, destroyed, 2 fatal. Probable cause: The pilot’s failure to maintain clearance from trees after entering a steep banked turn for unknown reasons. Contributing to the accident was the pilot’s decision to take off toward rising terrain. 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.