What happened
On July 12, 2011, an Aero Boero AB-115, registration PP-GRF, was performing an initial flight check for a Private Pilot license at the Aeroclube de Rondônia in Porto Velho, Brazil. During the final approach to runway 19, the aircraft struck a public lighting pole located approximately 250 meters from the runway threshold. Following this initial impact, the aircraft collided with high-voltage power lines roughly 25 meters further ahead. The aircraft subsequently struck the ground in a nose-down attitude and came to rest on its back. The two crew members—a student pilot and a flight examiner—sustained serious injuries.
The investigation
CENIPA's investigation focused on the sequence of events during the approach and the qualifications of the personnel involved. The investigation established that the student pilot was attempting to execute a correction requested by the examiner. The examiner, who was also acting as a Civil Aviation Inspector (INSPAC), had begun filling out the pilot evaluation form during the final approach, which diverted his attention from the flight path.
Investigators found that the student pilot was maintaining an approach slope that was significantly too low. When the examiner instructed the student to increase speed and correct the slope, the student applied power but abruptly pitched the nose down. Furthermore, the investigation revealed that the examiner's technical qualifications were invalid, as his single-engine land rating had expired. Additionally, the examiner lacked specific training on the AB-115 aircraft model.
Findings
- Improper control inputs: The student pilot's attempt to correct the approach resulted in an abrupt nose-down movement, leading to the collision.
- Distracted monitoring: The examiner's attention was diverted by administrative tasks (completing the evaluation form) during a critical phase of flight.
- Inadequate supervision: ANAC had authorized a flight check with an examiner whose technical ratings were expired.
- Lack of proficiency: The student's recent flight experience was minimal, having flown only eight hours in the year 2011, which likely impacted his judgment and control.
- Inadequate examiner training: The examiner lacked specific training on the aircraft type being evaluated.