# Oversight of maintenance - 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 maintenance - NTSB code: 04032020 - Cases: 28 - In the probable cause: 21 - Fatal cases: 11 - All cases: https://openairdocs.org/ntsb-findings/04032020/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04032020/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04032020 ## Cases per year (in the probable cause / all) - 2008: 1 / 1 - 2009: 1 / 1 - 2010: 2 / 3 - 2011: 1 / 1 - 2012: 1 / 1 - 2013: 3 / 3 - 2014: 1 / 1 - 2015: 2 / 4 - 2016: 3 / 3 - 2017: 1 / 2 - 2018: 2 / 2 - 2019: 1 / 1 - 2022: 2 / 4 - 2023: 0 / 1 ## Defining events in these cases - [Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340): 5 cases - [Part(s) separation from AC](https://openairdocs.org/ntsb-events/338): 3 cases - [Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333): 3 cases - [Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330): 3 cases - [Loss of engine power (total)](https://openairdocs.org/ntsb-events/341): 2 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 2 cases - [Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150): 2 cases - [Uncontained engine failure](https://openairdocs.org/ntsb-events/343): 1 cases - [Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342): 1 cases - [Aircraft structural failure](https://openairdocs.org/ntsb-events/337): 1 cases ## Aircraft models (registry) - [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p): 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 - [Swearingen SA226TC](https://openairdocs.org/model/swearingen-sa226tc): 1 cases - [Eurocopter SA315B](https://openairdocs.org/model/eurocopter-sa315b): 1 cases - [Sikorsky S-61N](https://openairdocs.org/model/sikorsky-s-61n): 1 cases - [Short Bros SD3-60 SHERPA](https://openairdocs.org/model/short-bros-sd3-60-sherpa): 1 cases - [Robinson Helicopter R22 BETA](https://openairdocs.org/model/robinson-helicopter-r22-beta): 1 cases - [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140): 1 cases - [Lockheed P2V-5F](https://openairdocs.org/model/lockheed-p2v-5f): 1 cases ## Other findings in the same cases - [Installation](https://openairdocs.org/ntsb-findings/02062035) (Personnel issues): 8 cases - [Scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010) (Personnel issues): 8 cases - [Post maintenance inspection](https://openairdocs.org/ntsb-findings/02061515) (Personnel issues): 6 cases - [Scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520) (Personnel issues): 4 cases - [Fuel](https://openairdocs.org/ntsb-findings/01071010) (Aircraft): 4 cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 3 cases - [Oversight of reg compliance](https://openairdocs.org/ntsb-findings/04032040) (Organizational issues): 2 cases - [Initial training](https://openairdocs.org/ntsb-findings/04031010) (Organizational issues): 2 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 2 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 2 cases ## Newest cases - [NTSB ENG23LA031](https://openairdocs.org/ntsb/ENG23LA031), Jun 28, 2023: Boeing 737-9 (N37516), Newark, NJ, incident, minor damage. Probable cause: A 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. - [NTSB WPR23LA017](https://openairdocs.org/ntsb/WPR23LA017), Oct 18, 2022: Cessna 177RG (N747ML), Mesa, AZ, substantial damage. Probable cause: The 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. - [NTSB CEN22LA228](https://openairdocs.org/ntsb/CEN22LA228), Jun 1, 2022: Air Tractor AT-602 (N5007R), Allport, AR, substantial damage. Probable cause: A 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… - [NTSB ERA22LA217](https://openairdocs.org/ntsb/ERA22LA217), May 1, 2022: Cessna 172N (N737LY), Toms River, NJ, substantial damage. Probable cause: Loss of engine power due to the throttle linkage becoming disconnected in flight due to improper maintenance. - [NTSB ANC22FA018](https://openairdocs.org/ntsb/ANC22FA018), Feb 22, 2022: Sikorsky S-61N (N615CK), Kekaha, HI, destroyed, 4 fatal. Probable cause: The 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.… - [NTSB WPR19MA177](https://openairdocs.org/ntsb/WPR19MA177), Jun 22, 2019: Beech 65-A90 (N256TA), Mokuleia, HI, destroyed, 11 fatal. Probable cause: The 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… - [NTSB WPR19LA010](https://openairdocs.org/ntsb/WPR19LA010), Oct 21, 2018: Piper PA46 (N413LL), Hurricane, UT, substantial damage. Probable cause: The 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… - [NTSB DCA18IA092](https://openairdocs.org/ntsb/DCA18IA092), Feb 13, 2018: Boeing 777 222 (N773UA), Honolulu, HI, incident, minor damage. Probable cause: the 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… - [NTSB WPR17LA180](https://openairdocs.org/ntsb/WPR17LA180), Aug 6, 2017: Lockheed P2V 5F (N410NA), Pocatello, ID, substantial damage. Probable cause: Maintenance 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… - [NTSB WPR17LA078](https://openairdocs.org/ntsb/WPR17LA078), Mar 20, 2017: Swearingen SA226 (N158WA), Boise, ID, substantial damage. Probable cause: Company 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… 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.