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Oversight of maintenance

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

All 28 cases21 in the probable cause
Cases
28
In the probable cause
21 (75%)
Fatal cases
11
NTSB code
04032020

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\", '04032020') 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\", '04032020'))
  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\", '04032020') 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 · 28

NTSB ENG23LA031Incident · No injuriesClass 3 · LimitedFinal reportBoeing 737-9 · Newark, NJA No. 1 (left) engine fire due a fuel leak that originated from the fuel nozzle 17 b-nut connection that was not properly torqued in accordance with the aircraft maintenance manual procedure.Jun 28, 2023 · N37516 · Minor damageNTSB WPR23LA017Accident · Serious injuriesClass 3 · LimitedFinal reportCessna 177RG · Mesa, AZThe failure of maintenance personnel to properly secure the fuel supply line to the fuel flow divider, which resulted in a fuel leak, fuel exhaustion, and a total loss of engine power.Oct 18, 2022 · N747ML · Substantial damageNTSB CEN22LA228Accident · Minor injuriesClass 3 · LimitedFinal reportAir Tractor AT-602 · Allport, ARA partial loss of engine power due to fuel contamination from foreign object debris. Contributing to the accident was the operator’s failure to follow the manufacturer’s required airframe fuel filter inspection interval.Jun 1, 2022 · N5007R · Substantial damageNTSB ERA22LA217Accident · No injuriesClass 4 · LimitedFinal reportCessna 172N · Toms River, NJLoss of engine power due to the throttle linkage becoming disconnected in flight due to improper maintenance.May 1, 2022 · N737LY · Substantial damageNTSB ANC22FA018Accident · 4 fatalClass 3 · FieldFinal reportSikorsky S-61N · Kekaha, HIThe improper installation of the fore/aft primary servo by maintenance personnel, which resulted in the attaching hardware backing out and which subsequently rendered the helicopter uncontrollable. Contributing to the accident was the company’s quality…Feb 22, 2022 · N615CK · DestroyedNTSB WPR19MA177Accident · 11 fatalClass 2 · MajorFinal reportBeech 65-A90 · Mokuleia, HIThe pilot’s aggressive takeoff maneuver, which resulted in an accelerated stall and subsequent loss of control at an altitude that was too low for recovery. Contributing to the accident were (1) the operation of the airplane near its aft center of gravity…Jun 22, 2019 · N256TA · DestroyedNTSB WPR19LA010Accident · Serious injuriesLimited investigationFinal reportPiper PA46 · Hurricane, UTThe mechanic’s failure to properly align the engine exhaust crossover pipe during replacement, and his supervisor’s failure to properly inspect the installation, which resulted in an in-flight fire and the loss of engine power.Oct 21, 2018 · N413LL · Substantial damageNTSB DCA18IA092Incident · No injuriesIncident investigationFinal reportBoeing 777 222 · Honolulu, HIthe fracture of a fan blade due to P&W's continued classification of the TAI inspection process as a new and emerging technology that permitted them to continue accomplishing the inspection without having to develop a formal, defined initial and recurrent…Feb 13, 2018 · N773UA · Minor damageNTSB WPR17LA180Accident · No injuriesLimited investigationFinal reportLockheed P2V 5F · Pocatello, IDMaintenance personnel's failure to secure hardware, which resulted in an uncommanded upward deflection of the left elevator and aft movement of the control yoke and inhibited the flight crew from adjusting the airplane's pitch attitude in flight. Contributing…Aug 6, 2017 · N410NA · Substantial damageNTSB WPR17LA078Accident · No injuriesLimited investigationFinal reportSwearingen SA226 · Boise, IDCompany maintenance personnel's failure to remove a screwdriver that was left lodged in the windshield wiper area of the forward fuselage during maintenance and subsequently became dislodged on takeoff/initial climb and collided with a left propeller blade.Mar 20, 2017 · N158WA · Substantial damage
See all 28 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\", '04032020'))
  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.