What happened
On October 7, 2020, a Robinson R22 Beta helicopter, registration PR-THR, was conducting a local instructional flight at the Piraquara Aerodrome (SISY) in Paraná, Brazil. The flight was intended as a transition/refresher session for a pilot returning to rotary-wing operations after a five-year hiatus.
During the training session, which included maneuvers such as traffic patterns and straight-and-level flight, the crew proceeded to practice hovering within ground effect and landing. During the third attempt at a hover maneuver, the student pilot applied abrupt and aggressive control inputs. This caused the aircraft to enter a sudden roll, leading to a dynamic rollover where the main rotor struck the ground. The impact caused substantial damage to the aircraft, though both the instructor and the student emerged uninjured.
The investigation
CENIPA's investigation focused on the sequence of events and the operational environment of the flight school. Investigators examined the flight records, maintenance logs, and the training protocols of the Civil Aviation Instruction Center (CIAC).
While the aircraft was found to be airworthy and the instructor was properly qualified, the investigation revealed significant deficiencies in the flight school's organizational structure. Specifically, the investigation found a lack of standardized training procedures, meaning instructors had total autonomy to decide on maneuvers without a set curriculum. Furthermore, investigators noted that flight training logs were often completed days late, lacked qualitative comments, and failed to track student progress effectively. The investigation also highlighted a lack of oversight from safety and quality management roles within the organization.
Findings
- The student pilot had not operated rotary-wing aircraft for approximately five years.
- The instructor exhibited an inappropriate attitude characterized by overconfidence and passivity, as he chose not to maintain physical control of the cyclic or collective during the maneuvers to allow the student more autonomy.
- The abrupt control inputs by the student pilot triggered the dynamic rollover.
- The flight school lacked standardized instruction, leading to improvised training sessions.
- There was a lack of effective managerial supervision and quality assurance regarding student performance and training documentation.