# Oversight of personnel - Type: NTSB finding subsection - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Support/oversight/monitoring](https://openairdocs.org/ntsb-findings/0403) › [Oversight](https://openairdocs.org/ntsb-findings/040320) › Oversight of personnel - NTSB code: 04032010 - Cases: 26 - In the probable cause: 21 - Fatal cases: 13 - All cases: https://openairdocs.org/ntsb-findings/04032010/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04032010/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04032010 ## Cases per year (in the probable cause / all) - 2008: 2 / 3 - 2010: 3 / 4 - 2011: 3 / 3 - 2012: 3 / 3 - 2013: 1 / 1 - 2014: 1 / 1 - 2015: 1 / 2 - 2016: 1 / 1 - 2017: 2 / 2 - 2018: 0 / 1 - 2022: 1 / 1 - 2023: 1 / 1 - 2024: 1 / 1 - 2025: 1 / 2 ## Defining events in these cases - [Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120): 4 cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 2 cases - [Inflight upset](https://openairdocs.org/ntsb-events/271): 2 cases - [Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260): 2 cases - [Ground resonance](https://openairdocs.org/ntsb-events/232): 2 cases - [Collision during takeoff/land](https://openairdocs.org/ntsb-events/490): 1 cases - [Loss of visual reference](https://openairdocs.org/ntsb-events/402): 1 cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 1 cases - [Loss of engine power (total)](https://openairdocs.org/ntsb-events/341): 1 cases - [Part(s) separation from AC](https://openairdocs.org/ntsb-events/338): 1 cases ## Aircraft models (registry) - [Short Bros. & Harland SD3-30](https://openairdocs.org/model/short-bros-harland-sd3-30): 1 cases - [Schweizer 269C-1](https://openairdocs.org/model/schweizer-269c-1): 1 cases - [Schweizer 269C](https://openairdocs.org/model/schweizer-269c): 1 cases - [Raytheon C90A](https://openairdocs.org/model/raytheon-c90a): 1 cases - [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300): 1 cases - [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180): 1 cases - [Piper PA-18-135](https://openairdocs.org/model/piper-pa-18-135): 1 cases - [Extra Flugzeugproduktions EA 300/L](https://openairdocs.org/model/extra-flugzeugproduktions-ea-300-l): 1 cases - [North American T-28C](https://openairdocs.org/model/north-american-t-28c): 1 cases - [Eurocopter Deutschland MBB-BK 117 C-2](https://openairdocs.org/model/eurocopter-deutschland-mbb-bk-117-c-2): 1 cases ## Other findings in the same cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 6 cases - [Training, general](https://openairdocs.org/ntsb-findings/04031000) (Organizational issues): 5 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 4 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 4 cases - [Low visibility](https://openairdocs.org/ntsb-findings/03035015) (Environmental issues): 3 cases - [Alcohol](https://openairdocs.org/ntsb-findings/02012015) (Personnel issues): 3 cases - [Performance/control parameters, general](https://openairdocs.org/ntsb-findings/01062000) (Aircraft): 3 cases - [Adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015) (Organizational issues): 2 cases - [Maintenance records](https://openairdocs.org/ntsb-findings/04033025) (Organizational issues): 2 cases - [Availability of policy/proc](https://openairdocs.org/ntsb-findings/04021010) (Organizational issues): 2 cases ## Newest cases - [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 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 DCA23FA339](https://openairdocs.org/ntsb/DCA23FA339), Jun 28, 2023: Boeing 717-200 (N955AT), Charlotte, NC, substantial damage. Probable cause: A fatigue fracture of the upper lock link that initiated along scratch features on the lower surface at the parting line of the forged aluminum component. Contributing to the accident was the… - [NTSB ANC23FA008](https://openairdocs.org/ntsb/ANC23FA008), Dec 15, 2022: Raytheon C90A (N13GZ), Kaupo, HI, substantial damage, 3 fatal. Probable cause: Guardian 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… - [NTSB ANC18FA053](https://openairdocs.org/ntsb/ANC18FA053), Jul 10, 2018: De Havilland DHC 3 (N3952B), Hydaburg, AK, substantial damage. Probable cause: The pilot's decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain. - [NTSB WPR18FA013](https://openairdocs.org/ntsb/WPR18FA013), Oct 21, 2017: Flugzeugproduktions-und Vertri EA 300/L (N414MT), Four Corners, CA, destroyed, 2 fatal. Probable cause: Collision with terrain after the pilot was unable to regain airplane control during an aerobatic maneuver. Contributing to the accident was the operator's failure to provide effective internal… - [NTSB DCA17FA109](https://openairdocs.org/ntsb/DCA17FA109), May 5, 2017: Short Bros. & Harland SD3 30 (N334AC), Charleston, WV, substantial damage, 2 fatal. Probable cause: the flight crew's improper decision to conduct a circling approach contrary to the operator's standard operating procedures (SOP) and the captain's excessive descent rate and maneuvering during the… - [NTSB DCA16MA204](https://openairdocs.org/ntsb/DCA16MA204), Jul 30, 2016: Kubicek BB85 (N2469L), Lockhart, TX, destroyed, 16 fatal. Probable cause: The pilot's pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot's ability to see and… - [NTSB GAA15CA202](https://openairdocs.org/ntsb/GAA15CA202), Jul 25, 2015: Bell 47G (N1420W), De Queen, AR, substantial damage. Probable cause: The pilot's failure to conduct helicopter performance planning, which resulted in an uncontrolled descent and impact with a truck and terrain during takeoff from an elevated platform. 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.