What happened
On March 16, 2009, an AB-180 aircraft, registration PP-FLT, was performing a local training flight at the Aeroclube de Santa Catarina (SSKT) in São José, Brazil. The flight was part of a flight instructor training mission, specifically focused on practicing maneuvers and simulated emergencies.
During the approach, the pilot executed a simulated emergency procedure. After touching down on the runway with all three wheels simultaneously, the pilot attempted to retract the flaps. During this action, the right wing lifted. In an attempt to maintain control, the pilot applied aileron input and rudder, but the aircraft drifted approximately 40 degrees to the right of the runway centerline. The pilot attempted a go-around; however, due to insufficient airspeed, the aircraft struck a fence and a small undulation in the terrain before coming to rest on its back, approximately 80 meters from the runway center.
The investigation
CENIPA's investigation examined the pilot's experience, the aircraft's maintenance history, and the operational environment of the flight school. The investigation found that while the pilot was qualified, they had limited experience with this specific aircraft model. The investigation also reviewed the aeroclube's safety management systems, including instructor supervision and flight training manuals.
Findings
- The pilot's judgment contributed to the accident, as they incorrectly believed they could clear obstacles during a go-around despite having insufficient airspeed.
- The pilot's application of controls contributed to the loss of directional control, as the pilot unconsciously used their feet to manipulate the flap lever while simultaneously attempting to use the rudder.
- There were deficiencies in the flight school's instructional materials; the Aeroclube's Flight Manual and Standard Operating Procedures (SOP) lacked information regarding common errors during landing and the proper procedures to follow after such errors occur.
- The investigation noted a lack of standardized supervision, as there was no designated person to monitor instructor and student performance records, and the evaluation forms lacked specific fields for learning levels and instructor comments.
- The aircraft sustained severe damage to the wing, fuselage, landing gear, engine, and propeller, though the pilot remained uninjured.
Safety action
CENIPA issued several recommendations to the Aeroclube de Santa Catarina, including the implementation of a procedure for daily monitoring of student performance records and the updating of the Aeroclube's Flight Manual and SOP to include common landing errors and recovery procedures. Additionally, CENIPA recommended that ANAC intensify its oversight of flight school instructional supervision and update official performance evaluation forms.