What happened
On June 15, 2007, at approximately 16:30, an IPE-02 glider, registration PP-FII, was performing a local instructional flight at the Itápolis Municipal Aerodrome in São Paulo. The aircraft was being towed by a P-56B aircraft for a training session conducted by the Aeroclube de Itápolis.
During the climb, the glider released from the tow plane before reaching the planned release altitude. Following the separation, the glider entered a left-hand descending spiral, a maneuver characterized as a spin-like attitude. The aircraft subsequently collided with the ground in a nearby orange grove. The accident resulted in two fatalities, involving both the instructor and the student, and caused extensive damage to the aircraft, rendering it a total loss.
The investigation
The CENIPA investigation examined the aircraft's maintenance records, the flight crew's experience, and the organizational structure of the flight school. Investigators found that while the aircraft's airworthiness documentation was in order and the tow plane was in adequate condition, several operational gaps existed. The investigation focused on the lack of standardized instruction, the absence of a formal flight training syllabus, and the lack of effective supervision by the aeroclube.
Findings
Several human and organizational factors contributed to the accident:
- Instructional Deficiencies: The flight school lacked a standardized training program, specifically omitting essential training for stall recovery and abnormal attitude recovery maneuvers. This lack of training likely hindered the crew's ability to recover the aircraft after the unexpected release.
- Supervisory Failures: The aeroclube failed to provide adequate oversight, allowing instruction to proceed without formal flight plans, standardized evaluation criteria, or a structured syllabus.
- Crew Coordination and Experience: The instructor, while qualified, had very limited experience as an instructor, having only received certification earlier that year. Additionally, the crew was performing their third flight of the day, and the lack of a specific pre-flight briefing for that mission, combined with the instructor's diverted attention to radio communications, likely led to poor cockpit coordination during the emergency.
- Organizational Culture: The investigation identified a low level of safety culture within the organization, characterized by subjective performance evaluations and a lack of standardized instructional procedures.