# Safety programs - Type: NTSB finding section - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Support/oversight/monitoring](https://openairdocs.org/ntsb-findings/0403) › Safety programs - NTSB code: 040350 - Cases: 38 - In the probable cause: 22 - Fatal cases: 30 - All cases: https://openairdocs.org/ntsb-findings/040350/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/040350/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/040350 ## Cases per year (in the probable cause / all) - 2008: 2 / 4 - 2009: 0 / 2 - 2010: 1 / 3 - 2011: 1 / 1 - 2012: 2 / 4 - 2013: 1 / 2 - 2015: 1 / 1 - 2016: 1 / 1 - 2017: 2 / 4 - 2018: 1 / 1 - 2019: 2 / 6 - 2020: 2 / 2 - 2021: 0 / 1 - 2022: 2 / 2 - 2023: 1 / 1 - 2024: 2 / 2 - 2025: 1 / 1 ## Findings - [Adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015): 24 cases, 15 in the probable cause - [Safety programs, general](https://openairdocs.org/ntsb-findings/04035000): 7 cases, 1 in the probable cause - [Adherence to safety program](https://openairdocs.org/ntsb-findings/04035020): 5 cases, 5 in the probable cause - [Availability of safety program](https://openairdocs.org/ntsb-findings/04035010): 4 cases, 3 in the probable cause ## Defining events in these cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 5 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 5 cases - [Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120): 4 cases - [Midair collision](https://openairdocs.org/ntsb-events/250): 3 cases - [Miscellaneous/other](https://openairdocs.org/ntsb-events/900): 2 cases - [Part(s) separation from AC](https://openairdocs.org/ntsb-events/338): 2 cases - [Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241): 2 cases - [Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470): 1 cases - [Landing area undershoot](https://openairdocs.org/ntsb-events/370): 1 cases - [Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342): 1 cases ## Aircraft models (registry) - [Eurocopter AS 350 B2](https://openairdocs.org/model/eurocopter-as-350-b2): 2 cases - [Diamond Aircraft Ind DA20-C1](https://openairdocs.org/model/diamond-aircraft-ind-da20-c1): 2 cases - [Cessna 208B](https://openairdocs.org/model/cessna-208b): 2 cases - [Boeing B-17G](https://openairdocs.org/model/boeing-b-17g): 2 cases - [Bell 206-L4](https://openairdocs.org/model/bell-206-l4): 2 cases - [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3): 1 cases - [Aerospatiale SA365N-1 DAUPHIN](https://openairdocs.org/model/aerospatiale-sa365n-1-dauphin): 1 cases - [Airbus Helicopters EC 130B4](https://openairdocs.org/model/airbus-helicopters-ec-130b4): 1 cases - [Sikorsky S-76B](https://openairdocs.org/model/sikorsky-s-76b): 1 cases - [Short Bros. & Harland SD3-30](https://openairdocs.org/model/short-bros-harland-sd3-30): 1 cases ## Other findings in the same cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 12 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 12 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 11 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 8 cases - [Incorrect action performance](https://openairdocs.org/ntsb-findings/02041015) (Personnel issues): 5 cases - [Altitude](https://openairdocs.org/ntsb-findings/01062012) (Aircraft): 5 cases - [Data recorders (flight/maint)](https://openairdocs.org/ntsb-findings/01023130) (Aircraft): 5 cases - [Not determined, general](https://openairdocs.org/ntsb-findings/05000000) (Not determined): 3 cases - [Oversight of personnel](https://openairdocs.org/ntsb-findings/04032010) (Organizational issues): 3 cases - [Training, general](https://openairdocs.org/ntsb-findings/04031000) (Organizational issues): 3 cases ## Newest cases - [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 CEN24MA111](https://openairdocs.org/ntsb/CEN24MA111), Feb 10, 2024: Airbus Helicopters EC 130 (N130CZ), Halloran Springs, CA, destroyed, 6 fatal. Probable cause: The 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… - [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 DCA23LA125](https://openairdocs.org/ntsb/DCA23LA125), Jan 14, 2023: Boeing 737-900ER (N914DU), Queens, NY, incident, no damage. Probable cause: The 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… - [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 ERA22FA004](https://openairdocs.org/ntsb/ERA22FA004), Oct 5, 2021: Dassault Falcon 20 (N283SA), Thomson, GA, destroyed, 2 fatal. Probable cause: The 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… - [NTSB ANC20FA017](https://openairdocs.org/ntsb/ANC20FA017), Feb 6, 2020: Piper PA32R (N7632C), Tuntutuliak, AK, substantial damage, 5 fatal. Probable cause: The 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… - [NTSB DCA20MA059](https://openairdocs.org/ntsb/DCA20MA059), Jan 26, 2020: Sikorsky S76 (N72EX), Calabasas, CA, destroyed, 9 fatal. Probable cause: The 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… - [NTSB ANC20MA010](https://openairdocs.org/ntsb/ANC20MA010), Dec 27, 2019: Airbus AS350B2 (N985SA), Kekaha, HI, destroyed, 7 fatal. Probable cause: The 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… 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.