What happened
On November 9, 2018, a Neiva 56-C, registration PP-GVQ, was performing a solo training flight at the Arthur Siqueira State Aerodrome (SBBP) in Bragança Paulista, Brazil. The flight was part of the student pilot's initial training program for a Private Pilot license. After completing the landing phase of the traffic pattern, the student pilot lost control of the aircraft, causing it to veer off the left side of the runway. The aircraft sustained substantial damage, though the student pilot remained uninjured.
The investigation
CENIPA's investigation revealed that the student pilot had completed several training sessions earlier that day, including a pre-solo phase. Notably, the student had received a failing grade on a previous flight that morning and had only been cleared for solo flight after a subsequent successful session. However, the investigation found that the student did not receive a formal debriefing following this final qualifying flight.
Investigators also examined the flight evaluation forms used by the flight school. They found that these forms lacked specific fields for recording required learning levels, making it difficult for instructors to accurately assess progress according to the established manual (MCA 58-3). Furthermore, there was evidence of a lack of managerial oversight at the flight school, as flight records showed inconsistencies in how practical exercises were graded and a lack of standardization regarding current regulations.
Findings
- Improper training progression: The student pilot was cleared for a solo flight following a day of inconsistent performance (one failing and one passing grade) without a proper debriefing.
- Inadequate evaluation tools: Flight evaluation forms did not include specific fields for learning levels, hindering accurate assessment.
- Lack of managerial oversight: Inconsistencies in grading and a lack of standardization in instructional norms were observed at the flight school.
- Pilot judgment: The student's ability to execute the flight safely was compromised by the lack of adequate instruction and supervision.
- Operational factors: The student pilot lacked experience in this specific type of flight and was still in the early stages of training.