What happened
On April 18, 2011, an Aeroboero AB-115, registration PP-GMA, was conducting a local instructional flight for a flight instructor candidate at the Londrina Aerodrome (SBLO) in Brazil. During the fourth touch-and-go maneuver, the pilot heard an unusual noise coming from the engine. Although engine parameters such as RPM, oil pressure, and oil temperature remained within normal limits, the pilot observed that the aircraft was unable to maintain a climb speed of 70 mph and was instead losing altitude.
Believing an engine failure was imminent, the pilot decided to return to the runway. During the subsequent approach, the pilot did not reduce engine power or deploy flaps. The aircraft touched down in the middle of the runway at a speed higher than normal. Realizing the aircraft could not stop within the remaining runway length, the pilot steered the aircraft to the right onto the grass area between taxiways A and B. While attempting to stop on the grass, the pilot applied the brakes, which caused the propeller to strike the ground. The pilot was uninjured, but the aircraft sustained severe damage.
The investigation
CENIPA investigators examined the aircraft's maintenance history and mechanical condition. Post-accident inspections, including fuel drain checks, magneto tests, spark plug inspections, and carburetor disassembly, revealed no mechanical abnormalities that could have caused an engine failure. The investigation also reviewed the pilot's training records and the flight school's instructional oversight. It was noted that the pilot's previous touch-and-go maneuvers had been performed without following the specific operational procedures for ground maneuvers, such as setting the 15-degree flap position and closing the carburetor heat.
Findings
- The pilot's improper application of aircraft controls during the landing phase led to the high-speed touchdown and subsequent runway excursion.
- The pilot failed to correctly evaluate the situation regarding the perceived engine issue, as engine parameters were normal, yet the pilot did not level the aircraft or verify if proper procedures had been followed during the previous ground maneuver.
- Inadequate instructional oversight at the flight school, where student evaluation forms were filled out superficially, hindered the effective monitoring of student progress.
- The aircraft's emergency briefing lacked specific items for memorization, particularly regarding engine failure procedures following takeoff.
Safety action
CENIPA issued several safety recommendations to the National Civil Aviation Agency (ANAC) regarding the Aeroclube de Londrina, including:
- Improving the quality of flight evaluation records to ensure effective management oversight.
- Reinforcing instruction regarding emergency procedures, specifically those following takeoff.
- Reviewing student instructional materials to ensure emergency memory items are clearly defined.
- Reviewing the intervals between instructional flights to ensure appropriate student progression.