What happened
While the provided source material focuses on safety recommendations rather than a specific accident narrative, the recommendations address systemic risks identified during the oversight of flight training operations. The focus is on the management of risks associated with training emergency procedures, particularly in light of evolving international standards.
The investigation
The investigation highlighted the need for more robust safety management systems within Flying Training Organisations (FTOs). The findings suggested that current audit and inspection processes may not sufficiently evaluate high-risk flight operations, such as the execution of emergency procedures, because these maneuvers are often not directly observed by auditors or inspectors during the audit process.
Findings
Several critical safety gaps were identified regarding the training of pilots in light twin-engine aircraft. A primary concern is the practice of simulating engine failures by actually shutting down an engine in flight for training purposes. To mitigate risk, it is recommended that engines should not be physically shut down during such maneuvers.
Furthermore, the investigation identified a need for better instructor preparation. There is a specific risk regarding the potential for student error during complex maneuvers, necessitating more thorough initial and annual recurrent training for novice instructors to recognize and manage the dangers of student mismanagement during flight execution.
Safety action
To address these risks, the Dutch Safety Board has issued several recommendations to the Minister of Infrastructure and Water Management and relevant aviation stakeholders:
- Encouraging FTOs to expand their JAR-FCL quality systems to include comprehensive safety management systems in anticipation of ICAO regulations.
- Increasing oversight during audits and inspections of high-risk flight operations, specifically those involving emergency procedure training.
- Prohibiting the actual shutdown of an engine in flight for training purposes in light twin-engine aircraft.
- Implementing rigorous training and annual refresher courses for new instructors to manage the risks of student error during flight operations.