What happened
On August 14, 2011, at approximately 11:45 UTC, an AeroBoero AB-115, registration PP-GMR, was performing a local training flight at Governador José Richa Airport (SBLO) in Londrina, Brazil. The aircraft was operated by Aeroclube de Londrina for private pilot training purposes.
The flight was the student pilot's first solo mission. Prior to the solo flight, the pilot had completed a 30-minute instructional flight with an instructor. During the first landing of the solo mission, the pilot lost control of the aircraft on the ground. The aircraft veered off the left side of the runway before the pilot was able to regain control and return the aircraft to the paved surface. The aircraft was subsequently taxied back to the apron under the guidance of the Londrina Tower. There were no injuries to the pilot and no damage was sustained by the aircraft.
The investigation
CENIPA's investigation focused on the pilot's training history and the flight school's oversight processes. Investigators reviewed flight evaluation records from the thirty days preceding the incident. These records revealed that the student pilot had a consistent history of difficulty executing landings, receiving "deficient" ratings in seven of the ten training missions leading up to the solo flight.
Furthermore, the investigation examined the administrative oversight of the flight training program. While the flight school had a designated practical instruction coordinator, there was no evidence in the flight logs that this individual was actively monitoring the student's progress. The evaluation fields intended for coordinator comments were left blank, indicating a lack of effective managerial supervision over the student's learning process.
Findings
- Inadequate control inputs during the landing phase led to the runway excursion.
- A fragile organizational culture regarding flight safety and instruction monitoring was present at the flight school.
- Lack of managerial supervision allowed the student to proceed to a solo flight despite documented, persistent difficulties with landing maneuvers.
- Deficiencies in the instructional process and organizational oversight contributed to the occurrence.