What happened
On August 1, 2008, a Piper PA-44 was conducting a training flight over the Adriatic Sea, approximately 20 nautical miles southwest of Zadar, Croatia. The flight, which included a flight instructor and a student, was intended to perform specific maneuvers as part of a syllabus, specifically training for minimum control speed (vMCA).
At approximately 12:29 local time, the aircraft disappeared from Croatian air traffic control radar. The aircraft had entered an uncontrolled flight state at an altitude of roughly 5,000 feet. Following a search operation, the wreckage was located on the seabed on August 3, 20 and successfully recovered the following day. The impact and subsequent crash resulted in two fatalities and the total destruction of the aircraft.
The investigation
The BFU investigation focused on the flight profile and the procedures used during the training maneuver. Investigators examined the aircraft's technical condition, finding no evidence of mechanical failure or engine malfunction contributing to the accident. The weather conditions at the time were found to be sufficient for flight and played no role in the event.
The investigation also scrutinized the Flight Training Organisation (FTO) and its operational manuals. It was noted that the procedures for conducting vMCA exercises were insufficiently described within the FTO's documentation. Furthermore, the investigation looked into the regulatory oversight provided by the German Aviation Authority (LBA), noting discrepancies between the approved training syllabus and the actual practices being performed by instructors.
Findings
- The aircraft entered a spin because the procedure used during the vMCA exercise provided a very low safety margin.
- The flight instructor failed to recognize the increasing danger during the maneuver and did not initiate necessary corrective actions in time.
- The training procedures for vMCA exercises within the FTO were inadequately defined and lacked standardization.
- There was a lack of clarity regarding the definition of "Airwork" within the training organization's manual.
- The aircraft was being operated at the very edge of its aerodynamic limits, specifically at the threshold where a spin becomes likely.