What happened
On June 5, 2009, a Socata TB200, registration CS-DEC, was performing a dual-instruction flight at Évora Aerodrome when it veered off the left side of runway 19. The flight, operated by the Academia Aeronáutica de Évora, was nearing the end of a training mission involving simulated engine failures.
During the base leg of the approach, the flight instructor intentionally reduced engine power to simulate an engine failure. At the time, weather conditions had deteriorated, with rain and a moderate 17-knot crosswind from the right. As the aircraft approached the runway, the student pilot struggled to maintain the centerline due to the crosswind and unfamiliarity with this specific runway.
As the aircraft touched down, it drifted left, nearly striking the left wingtip on the ground. During this critical phase, the instructor took control of the aircraft but failed to effectively communicate the transfer of control. The student pilot, unaware that the instructor had assumed command, applied opposite inputs by using right rudder and increasing power to pull the aircraft back onto the runway. This conflicting input caused the aircraft to accelerate and veer further off the paved surface into the adjacent terrain. The instructor eventually applied brakes and cut the fuel mixture to stop the aircraft, which finally came to a halt after the nose wheel struck a small hole and the propeller contacted the ground.
The investigation
The GPIAAF investigation focused on the breakdown in cockpit management and the environmental factors present during the landing. The investigators examined the student pilot's experience level, noting that he was performing his final mission before solo flight and was under significant psychological pressure due to the simulated emergency, the poor visibility, and the presence of an observer in the rear seat. The investigation also reviewed the flight instructor's decision-making regarding the continuation of the simulated failure maneuver under challenging weather conditions and the failure to establish a clear command handover.
Findings
- The primary cause of the incident was the loss of control of the aircraft during landing.
- A critical breakdown in crew resource management (CRM) occurred because the instructor did not effectively communicate the transfer of control ("my controls"), leading to simultaneous and contradictory control inputs from both the instructor and the student.
- The student pilot's limited experience prevented him from adequately compensating for the moderate right crosswind.
- The instructor utilized deficient instructional techniques by continuing a simulated engine failure maneuver under exceptional circumstances, including heavy rain, low visibility, and high-stress conditions for a novice pilot.
- The student pilot experienced high levels of anxiety due to the complexity of the mission and the presence of an observer.
Safety action
While no formal safety recommendations were issued, a preventive action proposal was made to the Academia Aeronáutica de Évora to emphasize training regarding student anxiety, aircraft control, crew resource management, and the limitations of landing in crosswind conditions.