# Oversight of operation - 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 operation - NTSB code: 04032015 - Cases: 61 - In the probable cause: 43 - Fatal cases: 40 - All cases: https://openairdocs.org/ntsb-findings/04032015/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04032015/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04032015 ## Cases per year (in the probable cause / all) - 2008: 2 / 3 - 2009: 2 / 5 - 2010: 0 / 2 - 2011: 3 / 3 - 2012: 2 / 5 - 2013: 5 / 8 - 2014: 3 / 3 - 2015: 6 / 7 - 2016: 4 / 4 - 2017: 4 / 4 - 2018: 1 / 1 - 2019: 3 / 4 - 2020: 1 / 2 - 2021: 1 / 1 - 2022: 2 / 2 - 2023: 1 / 2 - 2024: 1 / 3 - 2025: 2 / 2 ## Defining events in these cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 9 cases - [Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120): 8 cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 5 cases - [Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241): 4 cases - [Loss of control on ground](https://openairdocs.org/ntsb-events/230): 3 cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 2 cases - [Loss of engine power (total)](https://openairdocs.org/ntsb-events/341): 2 cases - [Aircraft structural failure](https://openairdocs.org/ntsb-events/337): 2 cases - [Abrupt maneuver](https://openairdocs.org/ntsb-events/270): 2 cases - [Midair collision](https://openairdocs.org/ntsb-events/250): 2 cases ## Aircraft models (registry) - [Eurocopter AS 350 B2](https://openairdocs.org/model/eurocopter-as-350-b2): 3 cases - [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3): 2 cases - [Boeing B-17G](https://openairdocs.org/model/boeing-b-17g): 2 cases - [WSK PZL Mielec M-18A](https://openairdocs.org/model/wsk-pzl-mielec-m-18a): 1 cases - [Weatherly 620B](https://openairdocs.org/model/weatherly-620b): 1 cases - [Vickers SPITFIRE MARK IX](https://openairdocs.org/model/vickers-spitfire-mark-ix): 1 cases - [Eurocopter AS 350 B2 ECUREUIL](https://openairdocs.org/model/eurocopter-as-350-b2-ecureuil): 1 cases - [Aerospatiale SA365N-1 DAUPHIN](https://openairdocs.org/model/aerospatiale-sa365n-1-dauphin): 1 cases - [Sikorsky S-61N](https://openairdocs.org/model/sikorsky-s-61n): 1 cases - [Saab-Scania 2000](https://openairdocs.org/model/saab-scania-2000): 1 cases ## Other findings in the same cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 23 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 18 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 14 cases - [Incorrect action selection](https://openairdocs.org/ntsb-findings/02041010) (Personnel issues): 8 cases - [Adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015) (Organizational issues): 7 cases - [Below VFR minima](https://openairdocs.org/ntsb-findings/03035075) (Environmental issues): 7 cases - [Incorrect action performance](https://openairdocs.org/ntsb-findings/02041015) (Personnel issues): 7 cases - [Angle of attack](https://openairdocs.org/ntsb-findings/01062042) (Aircraft): 7 cases - [Performance/control parameters, general](https://openairdocs.org/ntsb-findings/01062000) (Aircraft): 7 cases - [Safety](https://openairdocs.org/ntsb-findings/04024010) (Organizational issues): 6 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 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 OPS23FA010](https://openairdocs.org/ntsb/OPS23FA010), Aug 11, 2023: Boeing 737-7BD (N7734H), San Diego, CA, incident, no damage. Probable cause: The local control controller’s poor judgment in duty prioritization which distracted them from monitoring arriving and departing traffic and resulted in a runway incursion and loss of same runway… - [NTSB CEN23LA111](https://openairdocs.org/ntsb/CEN23LA111), Feb 19, 2023: Cessna 172K (N84688), Moline, IL, substantial damage. Probable cause: The student pilot’s failure to maintain directional control during the landing roll in gusting crosswind conditions. - [NTSB CEN23MA034](https://openairdocs.org/ntsb/CEN23MA034), Nov 12, 2022: Boeing B17 (N7227C), Dallas, TX, destroyed, 6 fatal. Probable cause: the air boss’s and air show event organizer’s lack of an adequate, prebriefed aircraft separation plan for the air show performance, relying instead on the air boss’s real-time deconfliction… - [NTSB ERA22FA279](https://openairdocs.org/ntsb/ERA22FA279), Jun 22, 2022: Bell UH-1B (N98F), Amherstdale, WV, destroyed, 6 fatal. Probable cause: the operator’s failure to adequately inspect the former military turbine powered helicopter, which allowed an engine issue to progress and result in a loss of engine power and a subsequent loss of… - [NTSB WPR21FA143](https://openairdocs.org/ntsb/WPR21FA143), Mar 28, 2021: Airbus Helicopters AS350-B3 (N351SH), Palmer, AK, substantial damage, 5 fatal. Probable cause: The pilot’s failure to adequately respond to an encounter with whiteout conditions, which resulted in the helicopter’s collision with terrain. Contributing to the accident was the (1) operator’s… 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.