What happened
On September 12, 2011, at approximately 19:10 UTC, an Aero Boero AB-115, registration PP-GRQ, was conducting a local flight training mission at the Bacacheri Aerodrome (SBBI) in Curitiba, Brazil. The flight, operated by Aeroclube do Paraná, carried an instructor and a student pilot as part of a Private Pilot (PPR) course training phase.
During the flight, the crew performed a series of touch-and-go maneuvers. Following the fourth touchdown, as the student pilot attempted to initiate a go-around, the aircraft's tail lifted, causing the student to lose directional control on the ground. The instructor immediately took control of the aircraft and applied brakes and rudder; however, the aircraft veered to the right side of the runway and entered the grass area, where the propeller struck the ground. Both occupants of the aircraft were uninjured, though the aircraft sustained light damage.
The investigation
CENIPA's investigation revealed that the student pilot had experienced significant gaps in training, with periods of inactivity lasting between one and three months due to adverse weather. Records indicated that the student had previously demonstrated difficulties maintaining directional control during takeoff, landing, and go-around phases.
The investigation also scrutinized the operational environment of the flight school. It was noted that the pre-flight briefing was conducted in only ten minutes in an inappropriate area of the operational apron, lacking detailed technical guidance. Furthermore, the investigation found that debriefings were often too short, and some instructors were performing up to five dual instruction flights per day, potentially compromising the quality of instruction.
Management oversight was also a key focus. The investigation found that the Course Coordinator and the Flight Instruction Director were not providing adequate supervision or standardized evaluation of student performance. Evaluation forms often lacked specific guidance or corrective recommendations, and there was a notable absence of a safety culture, evidenced by a lack of safety reports (RELPREV) filed by the operator in recent years.
Findings
- Inadequate command application by the student pilot during the go-around maneuver.
- Deficient managerial supervision by the flight school's course coordinator and instructional directors.
- Substandard flight instruction quality, characterized by insufficient briefing/debriefing and high instructor workloads.
- Lack of organizational safety oversight, including ineffective monitoring of student progress and a lack of proactive safety reporting.