What happened
On December 21, 1997, an AeroBoero AB-115, registration PP-GAS, operated by Aeroclube de Itápolis, departed from Itápolis Aerodrome for an instructor operational maintenance flight. After takeoff, the pilot performed a 180-degree turn to return over the departure runway.
At an altitude of approximately 120 ft, the pilot simulated an engine failure immediately after takeoff. The pilot then proceeded with procedures for a simulated emergency landing in an unprepared sugarcane field. At roughly 20 ft above the ground, the pilot attempted a go-around. Due to the low altitude and existing descending inertia, the engine did not respond quickly enough to the sudden power application. The right wing struck the ground, causing the aircraft to lose directional control and collide with the terrain. The aircraft sustained severe damage, but the pilot was uninjured.
The investigation
CENIPA's investigation focused on the execution of the training maneuver and the pilot's decision-making. Investigators found that the pilot failed to adhere to established training parameters, which required the engine failure simulation to begin at 500 ft and the go-around to be initiated at 300 ft. Instead, the pilot relied on visual estimation rather than consulting the altimeter.
The investigation also examined the pilot's psychological profile and operational procedures. It was noted that the pilot applied the throttle abruptly during the go-around, which delayed the engine's response. Furthermore, the investigation identified that the pilot's professional self-image and overconfidence led to a disregard for safety minimums and instrument monitoring.
Findings
- Overconfidence was the primary factor, as the pilot believed they could safely execute the maneuver at much lower altitudes than prescribed.
- The pilot failed to follow established flight discipline by ignoring the required minimum altitudes for both the simulated failure and the go-around.
- Deficient planning and judgment resulted in the pilot relying on visual cues rather than using the altimeter to monitor altitude.
- Improper engine power application (abruptly advancing the throttle) caused a delay in engine response during a critical phase of flight.
- The presence of a tailwind contributed to the difficulty of recovering the descent rate at such a low altitude.