What happened
On June 25, 2016, an Aero Boero AB-115, registration PP-GGG, was preparing for a local flight training mission at the Piracicaba Aerodrome (SDPW) in São Paulo, Brazil. The aircraft was occupied by an instructor and a student pilot. During the takeoff roll, the student pilot lost control of the aircraft, causing it to veer to the right. The left wingtip made contact with the ground, and the aircraft came to a stop at a heading of 220 degrees relative to the runway centerline. The incident resulted in minor damage to the aircraft, but both occupants were uninjured.
The investigation
The investigation conducted by SERIPA IV confirmed that the instructor was properly rated and held valid medical and flight instructor certifications. The aircraft was also in a condition for safe operation, with a valid airworthiness certificate, up-to-date maintenance logs, and proper weight and balance. No mechanical failures in the engine, flight controls, or aerodynamic surfaces were identified, and meteorological conditions were favorable for flight.
However, the investigation revealed significant deficiencies in the flight school's organizational processes. The flight training records lacked standardized levels of difficulty as prescribed by the Private Pilot Course Manual (MCA-58-3). This lack of structured progression meant that student progress could not be accurately monitored. Furthermore, the flight logs lacked a dedicated section for course coordinators to provide specific guidance to instructors, and there was no standardized manual for instructors regarding flight log completion or instructional standardization.
Findings
- Inadequate student assessment: The primary cause was the failure to accurately determine the student's capability to safely execute the assigned maneuver, effectively overestimating the appropriate level of instruction for the mission.
- Organizational deficiencies: The absence of standardized flight training levels and the lack of a specific instructor manual hindered the ability to track student performance effectively.
- Instructional oversight: There was evidence that the student's errors during the maneuver exceeded the instructor's ability to intervene timely, leading to the loss of control.
Safety action
At the time of the report's publication, the following recommendations were issued to the National Civil Aviation Agency (ANAC):
- Work with the Aeroclube de Piracicaba to align their flight training processes with the requirements of MCA-58-3, specifically regarding the use of evaluation forms that include all necessary fields for adequate flight recording.
- Assist the operator in improving instructional techniques, encouraging instructors to be more proactive and conservative to prevent student errors from reaching a point of irreversibility.