What happened
On June 13, 2015, a Piper PA-18, registration PP-GKX, was conducting a local instructional flight at the Novo Hamburgo Aerodrome (SSNH) in Rio Grande do Sul, Brazil. The flight, part of a Commercial Pilot course, carried an instructor and a student. After completing several maneuvers in the instructional area, the crew returned to the aerodrome to perform a touch-and-go maneuver followed by a final landing.
During the initial touchdown, the aircraft experienced a loss of control on the ground, leading to a capsize. The impact caused substantial damage to the engine, propeller, vertical stabilizer, rudder, and left wing. Both occupants of the aircraft escaped the incident without injury.
The investigation
CENIPA's investigation revealed that the flight was unplanned and lacked proper preparation. The student was in the process of leaving the flying club, and the club had arranged for this final instructional flight to utilize remaining flight hours. To meet the sudden demand, the club called upon a more experienced instructor at the last minute, which prevented adequate pre-flight planning.
Crucially, no pre-flight briefing was conducted between the instructor and the student. During the flight, disagreements arose regarding flight parameters, such as altitude. The investigation established that during the landing phase, the student attempted a runway landing while the instructor was expecting a three-point landing. The instructor, feeling the student's technique was dangerous, experienced a loss of situational awareness and a diminished capacity for critical judgment. This led to a conflict within the cockpit where flight controls were used arbitrarily by both occupants, ultimately causing the loss of control.
Furthermore, the investigation highlighted significant organizational failures. The instructor and student both had very limited experience in the Piper PA-18, with the instructor having only 18 hours and the student only 10 hours in the model. The investigation also noted a lack of managerial oversight, as student flight logs lacked proper coordination reviews, and the club's organizational culture lacked adherence to standard safety procedures, such as mandatory briefings.
Findings
- Loss of control on the ground due to conflicting control inputs and lack of coordination.
- Poor Crew Resource Management (CRM) and communication between the instructor and student.
- Absence of a pre-flight briefing to establish flight criteria and rules.
- Inadequate flight planning and sudden assignment of crew.
- Lack of effective supervision and instructional oversight by the flying club.
- Limited experience of both crew members in the specific aircraft model.
- Deficient organizational culture regarding safety procedures and managerial supervision.