What happened
On August 2, 2017, at 15:51 UTC, a Cessna 152, registration CS-AVA, operated by EAA - Escola de Aviação Aerocondor, was conducting a training flight near Praia de São João da Caparica, Portugal. During the flight, the aircraft experienced an in-flight engine shutdown, which subsequently led to a loss of control. The aircraft was operating in an area where the flight path over water presented a risk of an emergency ditching.
The investigation
The GPIAAF investigation examined the mechanical and operational aspects of the occurrence, focusing on the engine's failure and the crew's response. The investigation reviewed the aircraft's maintenance records, the fuel system, and the carburetor mechanism. Additionally, the investigators scrutinized the flight school's operational procedures, specifically the Standard Operating Procedures (ESOP) used by the crew, and compared them against the aircraft's Pilot Operating Handbook (POH). The investigation also looked into the instructor's management of the emergency and the school's risk analysis regarding over-water operations.
Findings
- The investigation identified that the aircraft's ESOP did not reflect significant changes found in the aircraft's POH and was not validated by the National Civil Aviation Authority (ANAC).
- There was a lack of a formal operational risk analysis for the flight school regarding single-engine land operations at Cascais Airport (LPCS), particularly concerning the risks associated with flying over water.
- The instructor's management of the emergency and the techniques used during the loss of control indicated a lack of standardized emergency procedures.
- A significant increase in incidents involving training flights and the direct involvement of instructors in recent national occurrences was noted.
Safety action
- Safety Recommendation No. 15/2018: It is recommended that the National Civil Aviation Authority (ANAC) evaluate the current flight instructor standardization process within Approved Training Organizations (ATOs), proposing and implementing improvements to the evaluation of instructor performance.