What happened
On July 22, 2012, at approximately 16:00 UTC, an IPE-02B glider, registration PP-FJF, was conducting a flight instruction mission at the Bebedouro Aerodrome (SDBB) in São Paulo, Brazil. The flight, operated by Aeroclube de Bebedouro, carried an instructor and a student pilot. After being released from a tow plane at an altitude of 639 meters, the instructor notified the tower that they would begin training for a simulated spoiler failure.
During the maneuver, the glider entered the traffic pattern for runway 13 with the spoilers deployed. The aircraft began to lose altitude at an increased rate. As the glider performed a holding pattern, it operated at altitudes lower than those prescribed by the flight club's manual. While on the downwind leg, the aircraft maintained a descent rate of approximately 4.8 m/s at a speed of 81 km/h. The glider eventually collided with the ground near the threshold of runway 13, resulting in substantial damage to the aircraft. The student pilot sustained fatal injuries, while the instructor suffered serious injuries.
The investigation
CENIPA's investigation focused on the flight dynamics and the crew's management of the simulated emergency. Investigators noted that the flight club's manual required specific altitudes for the holding pattern, which were not maintained during this flight. Furthermore, the investigation found that the IPE-02B flight manual lacked specific performance data, such as glide ratios or vertical speeds, when operating with spoilers deployed. This lack of technical guidance forced the crew to rely on empirical estimation during the training.
Analysis of the flight path revealed that if the spoilers had been retracted, the estimated altitude loss would have been only 51 meters, which would have likely allowed for a safe landing. The investigation also examined the crew's interaction, noting that the instructor did not intervene in the controls despite the increasingly risky flight profile being flown by the student.
Findings
- The primary cause was the execution of a standard approach profile while experiencing an increased vertical descent rate due to the deployed spoilers, combined with a lack of standardized procedures for simulated failure training.
- The instructor's passive attitude and failure to intervene in the controls contributed to the accident.
- A loss of situational awareness by the instructor prevented the identification of the developing risk.
- Errors in judgment and decision-making regarding the flight profile and the lack of corrective actions during the maneuver.
- Inadequate technical support in the aircraft's manual regarding performance under spoiler-deployed configurations.
- Inconsistencies in the flight club's operational manuals regarding standard traffic patterns.