What happened
On November 24, 2011, a Piper PA-28-140, registration PT-IZS, was performing a flight instruction mission from Campo de Marte (SBMT) to Atibaia (SDTB). The flight began with an instructor and a student pilot on board. After completing three touch-and-go maneuvers, the instructor exited the aircraft to allow the student to perform his first solo flight.
During the solo operation, the student successfully completed the takeoff, traffic pattern, and approach phases. However, during the landing roll on runway 02, the aircraft experienced a loss of directional control. The aircraft veered left and exited the runway, eventually colliding with a ground obstacle (part of a sign) approximately 610 meters from the runway threshold. The aircraft sustained substantial damage, but the pilot remained uninjured.
The investigation
CENIPA's investigation examined the training procedures of the flight school and the pilot's performance. Investigators found that the student was progressing normally in his Private Pilot training, though flight evaluation records lacked detailed qualitative data regarding speed maintenance.
The investigation also identified a lapse in instructional supervision: the instructor had released the student for his solo flight without conducting a formal briefing or debriefing, a practice used by the club to expedite instruction. Furthermore, the investigation noted that the student's lack of experience contributed to a degradation in situational awareness during the high-stress final stages of the landing roll.
Findings
- Asymmetric braking: The pilot applied differential braking with higher pressure on the left pedal to correct a rightward drift, which ultimately caused the aircraft to veer off the runway.
- Pilot judgment: Inadequate judgment regarding approach speed, which was likely slightly above the target 70 MPH, and improper simultaneous control of the pedals during the landing roll.
- Lack of experience: The student pilot lacked the experience necessary to manage the cognitive demands and physical inputs required during an irregular landing roll.
- Supervisory deficiencies: Inadequate management oversight regarding the necessity of pre-solo briefings and the quality of flight evaluation documentation.