What happened
On March 5, 2020, an Aero Boero AB-115, registration PP-FLF, was conducting a local flight instructor training mission at the Rio Claro Aerodrome (SDRK) in São Paulo, Brazil. The aircraft was occupied by two crew members: an instructor and a student instructor.
During the flight, at an altitude of approximately 800 feet, the instructor initiated a simulated engine failure exercise. The student instructor was operating the controls from the rear cockpit. While performing the maneuver, the student instructor executed a left turn toward the opposite runway threshold (Runway 03) at an angle of approximately 45 degrees from the runway centerline. This resulted in an unstable approach characterized by an excessive descent rate and high airspeed.
Upon touchdown, the aircraft's nose wheel remained off the ground, and the landing occurred past the first third of the runway. During the rollout, both crew members applied the brakes simultaneously without proper communication. This uncoordinated braking caused the aircraft to lose control and capsize, resulting in substantial damage to the aircraft and minor injuries to both occupants.
The investigation
CENIPA's investigation focused on the decision-making processes and cockpit coordination during the training maneuver. Investigators found that the instructor, while aware that the approach was improper, did not intervene or cancel the simulated emergency, despite the fact that the aircraft lacked the performance to execute a go-around once full flaps were selected.
The investigation also examined the lack of formal stabilized approach criteria within the flight school's operations. Furthermore, the investigation highlighted a failure in positive command transfer; the instructor applied the brakes without informing the student, leading to the simultaneous and conflicting application of braking force.
Findings
- Unstable approach: The student instructor performed a non-stabilized approach with an incorrect glide path and excessive speed.
- Inadequate judgment: The instructor failed to intervene or abort the simulated failure when the approach became unsafe.
- Lack of coordination: There was no positive transfer of controls or communication regarding braking, leading to simultaneous brake application.
- Pilot experience: While the instructor was qualified, the student instructor had limited experience in this specific type of flight maneuver.
- Organizational factors: The flight school lacked formal, objective criteria for stabilized approaches and standardized procedures for command transfer.