What happened
On November 5, 2015, at approximately 19:15 UTC, a Neiva 56-C, registration PP-GSZ, was performing a local flight instruction mission at the Bragança Paulista Aerodrome (SBBP) in São Paulo, Brazil. The aircraft, operated by Aeroclube de Bragan $ança Paulista, was conducting a Phase I Pre-Solo review flight with an instructor and a student pilot on board.
During the takeoff roll on runway 34, the aircraft experienced a loss of directional control and veered to the left side of the runway. The instructor attempted to intervene by reducing power and taking control of the rudder pedals, but was unable to correct the lateral displacement. The aircraft exited the runway to the left and came to a stop in a grassy area. The impact resulted in light damage to the left main landing gear and the left wingtip. Both occupants were uninjured.
The investigation
CENIPA's investigation focused on the student's training progress and the flight school's instructional oversight. The investigation confirmed that the instructor was properly qualified and that the aircraft was airworthy, within weight and balance limits, and that meteorological conditions were favorable for flight.
Investigators reviewed the student's flight logs, which revealed a pattern of difficulty with aircraft control. Out of 17 flight logs, seven were marked as deficient. Specifically, previous logs noted the student's struggle with rudder application during takeoff and difficulty maintaining the runway centerline during maneuvers. The investigation also noted that the student had recently completed a review mission where they received poor grades for both takeoff and landing performance.
Findings
- Improper application of controls by the student pilot during the takeoff roll.
- Inadequate cockpit coordination between the instructor and student.
- Deficiencies in instructional oversight, as there was no evidence of effective supervision or a holistic analysis of the student's performance by the flight school's management.
- Organizational weaknesses within the flight school regarding the implementation of instructional tools and feedback mechanisms to address student performance gaps.
Safety action
CENIPA issued a recommendation to the National Civil Aviation Agency (ANAC) to work with the Aeroclube de Bragança Paulista to improve flight instruction supervision and standardize instructor procedures.