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

All 38 cases22 in the probable cause
Cases
38
In the probable cause
22 (58%)
Fatal cases
30
NTSB code
040350

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\", '040350') 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.

Subsections · 4

Query with SQL
duckdb -csv -c "SELECT left(f.\"findingCode\", 8) AS code, max(f.\"tier4Name\") AS name,
    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
  WHERE starts_with(f.\"findingCode\", '040350') AND f.\"findingCode\" GLOB '[0-9][0-9]*'
  GROUP BY 1
  ORDER BY cases DESC, code"

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\", '040350'))
  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\", '040350') 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 · 38

NTSB DCA25MA108Accident · 67 fatalClass 1 · MajorFinal reportBombardier CL-600-2C10 · Washington, DCThe 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 available data, and their failure to act on recommendations to…Jan 30, 2025 · N709PS · 2 aircraft · DestroyedNTSB CEN24MA111Accident · 6 fatalClass 2 · MajorFinal reportAirbus Helicopters EC 130 · Halloran Springs, CAThe pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control. Contributing to the accident was the company’s inadequate oversight of its…Feb 10, 2024 · N130CZ · DestroyedNTSB DCA24MA063Accident · Minor injuriesClass 1 · MajorFinal reportBoeing 737-9 · Portland, ORthe 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 personnel could consistently and correctly comply with its…Jan 6, 2024 · N704AL · Substantial damageNTSB DCA23LA125Incident · No injuriesClass 1 · LimitedFinal reportBoeing 737-900ER · Queens, NYThe American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air…Jan 14, 2023 · N914DU · 2 aircraft · No damageNTSB CEN23MA034Accident · 6 fatalClass 1 · MajorFinal reportBoeing B17 · Dallas, TXthe 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 directives and the see-and-avoid strategy for collision avoidance,…Nov 12, 2022 · N7227C · 2 aircraft · DestroyedNTSB ERA22FA279Accident · 6 fatalClass 1 · FieldFinal reportBell UH-1B · Amherstdale, WVthe 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 control after the helicopter struck powerlines during a forced…Jun 22, 2022 · N98F · DestroyedNTSB ERA22FA004Accident · 2 fatalClass 3 · FieldFinal reportDassault Falcon 20 · Thomson, GAThe flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with…Oct 5, 2021 · N283SA · DestroyedNTSB ANC20FA017Accident · 5 fatalClass 3 · FieldFinal reportPiper PA32R · Tuntutuliak, AKThe pilot's continued visual flight rules flight into reduced visibility, including likely flat light and/or white out conditions, which resulted in a controlled flight into terrain. Contributing to the accident were the operator’s inadequate operational…Feb 6, 2020 · N7632C · Substantial damageNTSB DCA20MA059Accident · 9 fatalClass 1 · MajorFinal reportSikorsky S76 · Calabasas, CAThe pilot’s decision to continue flight under visual flight rules into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control. Contributing to the accident was the pilot’s likely self-induced pressure…Jan 26, 2020 · N72EX · DestroyedNTSB ANC20MA010Accident · 7 fatalClass 1 · MajorFinal reportAirbus AS350B2 · Kekaha, HIThe pilot’s decision to continue flight under visual flight rules (VFR) into instrument meteorological conditions (IMC), which resulted in the collision into terrain. Contributing to the accident was Safari Aviation Inc.’s lack of safety management processes…Dec 27, 2019 · N985SA · Destroyed
See all 38 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\", '040350'))
  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.