What happened
On November 1, 2019, at approximately 20:45 UTC, a Piper PA-18, registration PP-GJI, was performing a local flight instruction mission at the Luziânia Aerodrome (SWUZ) in Goiás, Brazil. The aircraft was occupied by an instructor and a student pilot.
During the takeoff roll, the right tire burst, causing the aircraft to veer off the right side of the runway. The aircraft traveled approximately 15 and 50 meters off the paved surface before colliding with several trees. While the aircraft sustained substantial damage, both occupants escaped the incident without injury.
The investigation
CENIPA investigators examined the aircraft's maintenance records and the operational procedures of the flight school. The investigation focused on the mechanical failure of the tire and the regulatory status of the crew.
Investigators found that the instructor's medical certificate and flight instructor ratings had expired in September 2019, rendering the pilot unqualified for the flight. Furthermore, the investigation revealed that the flight school lacked a standardized, mandatory checklist for pre-flight inspections, with pilots relying instead on personal experience.
Regarding the mechanical failure, the investigation noted that the right tire burst during the takeoff roll. While the aircraft's airworthiness certificate was valid, the inspection of the landing gear revealed that the tire lacked "witness marks" (lines of faith) to indicate proper alignment between the tire and the wheel. The investigation also found that the left and auxiliary tires had displaced markings, suggesting a lack of regular inspection for tire slippage or proper inflation.
Findings
- The right tire burst during the takeoff roll, leading to the loss of directional control.
- The flight school demonstrated an inadequate organizational culture, as pilots did not regularly inspect tire inflation or condition.
- The instructor was operating with an expired medical certificate and expired flight instructor ratings.
- The operator failed to provide adequate managerial supervision, allowing an unqualified instructor to conduct flight training.
- The lack of standardized pre-flight checklists contributed to the failure to identify improper tire inflation or alignment issues.