What happened
On April 14, 2022, a near mid-air collision occurred within the Babice Aerodrome Traffic Zone (ATZ) while two aircraft were performing landing approaches to runway 10R at EPBC airport. The first aircraft, a Cessna 152 (registration SP-KOG) operated by Aeroklub Warszawski, was being flown solo by a student pilot under the remote supervision of an instructor on the ground. The second aircraft, a Piper PA28-181 (registration SP-FFR) operated by Runway Pilot School, was performing standard circuit patterns with a crew consisting of a flight instructor and a student pilot.
During the climb phase of the Cessuna 152's solo flight, the intake manifold disconnected from the upper left air intake, causing a significant influx of air into the cockpit. The student pilot identified this as an emergency and decided to terminate the flight. To expedite the landing, the student pilot executed the third turn prematurely, deviating from the standard circuit pattern at EPBC. Due to intense focus on the emergency and limited experience, the student pilot failed to notice the Piper PA28-181 approaching from the left. The Piper PA28-181 crossed the flight path of the Cessna 152, resulting in a dangerous reduction in separation. The crew of the Piper PA28-181 attempted to establish radio contact with the student pilot but were initially unsuccessful. The student pilot only became aware of the other aircraft after a second radio contact alerted them to the presence of the Piper PA28-181 below and to their left. The student pilot subsequently aborted the approach and performed a proper second circuit, landing safely.
The investigation
The PKBWL examined the flight sequences, radio communications, and the technical failure of the Cessna 152. The investigation focused on the student pilot's deviation from standard procedures, the lack of communication regarding the cockpit malfunction, and the lack of support from the ground-based instructor during the emergency.
Findings
- The primary cause of the incident was the loss of situational awareness by the student pilot and the execution of a non-standard third turn.
- The student pilot failed to report the cockpit malfunction on the Babice radio frequency, which would have explained the sudden change in flight path.
- The supervising instructor did not take active measures to support the student pilot during the emergency.
Safety action
- The training organization (ATO) provided the student pilot with additional training on a Flight Simulation Training Device (FSTD), specifically covering emergency procedures and appropriate radio communication protocols.