# Adequacy of safety program - Type: NTSB finding subsection - Path: [Organizational issues](https://openairdocs.org/ntsb-findings/04) › [Support/oversight/monitoring](https://openairdocs.org/ntsb-findings/0403) › [Safety programs](https://openairdocs.org/ntsb-findings/040350) › Adequacy of safety program - NTSB code: 04035015 - Cases: 24 - In the probable cause: 15 - Fatal cases: 17 - All cases: https://openairdocs.org/ntsb-findings/04035015/cases.md - Cases with it in the probable cause: https://openairdocs.org/ntsb-findings/04035015/cases.md?cause=1 - Page: https://openairdocs.org/ntsb-findings/04035015 ## Cases per year (in the probable cause / all) - 2008: 1 / 1 - 2009: 0 / 1 - 2010: 1 / 3 - 2011: 1 / 1 - 2012: 0 / 2 - 2013: 1 / 1 - 2015: 1 / 1 - 2017: 1 / 2 - 2019: 2 / 5 - 2020: 1 / 1 - 2022: 2 / 2 - 2023: 1 / 1 - 2024: 2 / 2 - 2025: 1 / 1 ## Defining events in these cases - [VFR encounter with IMC](https://openairdocs.org/ntsb-events/401): 4 cases - [Part(s) separation from AC](https://openairdocs.org/ntsb-events/338): 2 cases - [Midair collision](https://openairdocs.org/ntsb-events/250): 2 cases - [Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241): 2 cases - [Loss of control in flight](https://openairdocs.org/ntsb-events/240): 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 - [Loss of engine power (total)](https://openairdocs.org/ntsb-events/341): 1 cases - [Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333): 1 cases ## Aircraft models (registry) - [Diamond Aircraft Ind DA20-C1](https://openairdocs.org/model/diamond-aircraft-ind-da20-c1): 2 cases - [Boeing B-17G](https://openairdocs.org/model/boeing-b-17g): 2 cases - [Eurocopter AS 350 B2](https://openairdocs.org/model/eurocopter-as-350-b2): 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 - [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44): 1 cases - [Mooney M20E](https://openairdocs.org/model/mooney-m20e): 1 cases - [Hughes OH-6A](https://openairdocs.org/model/hughes-oh-6a): 1 cases - [Hiller UH-12E](https://openairdocs.org/model/hiller-uh-12e): 1 cases - [Dehavilland DHC-2 MK. I(L20A)](https://openairdocs.org/model/dehavilland-dhc-2-mk-i-l20a): 1 cases ## Other findings in the same cases - [Oversight of operation](https://openairdocs.org/ntsb-findings/04032015) (Organizational issues): 7 cases - [Decision making/judgment](https://openairdocs.org/ntsb-findings/02041520) (Personnel issues): 7 cases - [Adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015) (Organizational issues): 6 cases - [Aircraft control](https://openairdocs.org/ntsb-findings/02063040) (Personnel issues): 5 cases - [Data recorders (flight/maint)](https://openairdocs.org/ntsb-findings/01023130) (Aircraft): 4 cases - [Not determined, general](https://openairdocs.org/ntsb-findings/05000000) (Not determined): 3 cases - [Incorrect action performance](https://openairdocs.org/ntsb-findings/02041015) (Personnel issues): 3 cases - [Altitude](https://openairdocs.org/ntsb-findings/01062012) (Aircraft): 3 cases - [Airspeed](https://openairdocs.org/ntsb-findings/01062010) (Aircraft): 3 cases - [Oversight of reg compliance](https://openairdocs.org/ntsb-findings/04032040) (Organizational issues): 2 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 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 ERA20MA001](https://openairdocs.org/ntsb/ERA20MA001), Oct 2, 2019: Boeing B17 (N93012), Windsor Locks, CT, destroyed, 7 fatal. Probable cause: The pilot’s failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb. Contributing to the… - [NTSB ERA19LA253](https://openairdocs.org/ntsb/ERA19LA253), Aug 21, 2019: Velocity XL-5 (N735D), St. Cloud, FL, substantial damage. Probable cause: The pilot’s failure to properly secure the airplane electrical system’s positive/negative leads to the 24v battery, which resulted in a total loss of electrical and engine power in flight. 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.