What happened
On September 12, 2011, an Aero Boero AB-115, registration PP-FLX, was conducting a local flight training mission at the Santa Maria Aerodrome in Rio Grande do Sul, Brazil. The crew consisted of an instructor and a student pilot undergoing training for a Private Pilot License. The weather conditions were favorable, with calm winds and unrestricted visibility.
During the flight, the student pilot initially operated the aircraft until the traffic pattern, at which point the instructor assumed control for the landing phase. After the first touchdown, the aircraft briefly climbed back into the air. Upon the second touchdown, the aircraft began to drift to the left. The instructor attempted to correct the deviation using right rudder and subsequently applied the right brake. During this maneuver, the aircraft's tail lifted, leading to a nose-over (piloning) position. The aircraft sustained light damage to the engine and propeller, but both occupants were uninjured.
The investigation
CENIPA's investigation revealed significant organizational deficiencies within the flight school. The investigation established that the flight club lacked a formal Mission Plan, which should define specific exercises and proficiency levels for students. Consequently, there was no standardized way to verify if instructors were meeting required training benchmarks.
Furthermore, the investigation found that the instructor's specific training in directional control using brakes had not been adequately documented or evaluated. The lack of a Flight Safety Director and the absence of safety reports (RELPREV) during 2011 suggested a weak safety culture and insufficient management oversight within the organization.