INTRODUCTION: Flight training is generally considered one of the safest categories of general aviation; however no type of flying is without risk. The purpose of this study was to identify risk factors for accidents involving flight instruction in fixed-wing aircraft. METHODS: National Transportation Safety Board accident data were used to identify accidents that occurred during instructional flights in fixed-wing aircraft during 1999- 2010. Instructional flights were a part of flight training, those that required instructor supervision or presence onboard. Narrative reports were reviewed to determine primary or secondary student status and whether a flight instructor was present. Data were then analyzed to determine phase of flight, location, circumstances and causes. RESULTS: During 1999-2010, 2488 instructional flights were involved in 2474 accidents during civilian flight training operations, resulting in 491 fatalities and 290 serious injuries. The majority of these instructional flights involved primary students (67%, 1673) and over half (55%, 1370) occurred with a certificated flight instructor in the airplane. The most frequent occurrences were loss of control on ground or water (24%), loss of control in flight (15%), hard landing (15%) and loss of engine power (13%). One hundred accidents resulted from fuel starvation or exhaustion; 65 of these accidents had instructors in the aircraft. Instructor's inaction or improper action was identified by the NTSB as a primary factor in almost half (48%, 659) of the accident flights with an instructor onboard. A majority of the accidents occurred on an airstrip (68%); the most common phases of flight in which accidents took place were landing (34%, 857) and takeoff (12%, 297). DISCUSSION: These data indicate a need for increased attentiveness and improved supervision of students by flight instructors. Instructor proficiency in emergency procedures and maneuvers and setting conservative criteria for safe flight operations, including fuel reserves, winds and altitudes may prevent future accidents. Capable instructors may prevent accidents during dual flight and by imparting the skills, knowledge and judgment for safe solo flight by students.