When a private plane or helicopter crashes the National Transportation Safety Board typically blames the pilot. However a USA Today investigation is questioning the legitimacy of so many "pilot error" rulings. Federal investigators failed to find safety problems with small aircraft making them potentially unfit for flight.
His watch, his business cards, his phone. Tricia Coffman cherishes these everyday things her husband Dave had on the last day of his life. The Circuit City executive was a passenger on Cessna Citation charter plane. It went down near the Pueblo, Colorado, airport in 2005.
"I just remember sitting on the floor and crying," said Coffman.
Eight people died in the Pueblo crash. Over the past five decades, nearly 45,000 people have been killed in private planes and helicopters, general aviation. That's roughly nine times the number of people who died in commercial crashes. And while the rate of commercial crashes has dropped significantly, the rate of small plane crashes and deaths have not changed significantly in 15 years.
"Everyone in the community understands… we've got to do better when it comes to GA," said Deborah Hersman, former NTSB chairman.
The NTSB cited pilots as a cause of 86 percent of general aviation crashes, including the Pueblo crash. But a series of civil lawsuit results contradict the NTSB's crash report conclusions, blaming aircraft design flaws instead.
Our partners at USA TODAY found 21 verdicts totaling nearly $1 billion against manufacturers that the NTSB had exonerated.
"Very frequently the investigations done by private parties in litigation is more substantial than what was done by NTSB. And we often find what really happened," said Thomas Byrne, an aviation attorney who represents manufacturers.
So why do the government's own air safety experts miss these safety problems?
"They often don't even go to the accident scene and they rely upon first responders," said Byrne.
"Many times they'll turn the evidence, the engine, over to the engine manufacturer to do a teardown at the manufacturer's facility, often there is not even an NTSB member present," said Bruce Lampert, an aviation attorney who represents pilots.
"Here at the NTSB, our single goal is safety," said John DeLisi, NTSB Director of Aviation Safety.
The NTSB says its resources are stretched thin.
"The average investigator is doing 30 to 40 investigations over the course of the year," said Hersman. "They are not going to be able to do a deep dive on every single accident."
The NTSB says they work on special reports looking for trends in the accident data they collect.
"We are a very transparent agency, all of the work that we do we make available to the public. And hopefully they will use it to prevent future accidents."
Because there can be grave consequences when the NTSB gets it wrong.
"If you continually blame the pilots, these institutional defects in the aircraft, in the engine, go on unrepaired unfixed and continue to cause additional accidents in the future," said Lampert.