What happened
On September 25, 1998, an Aeroboero AB-115, registration PP-GRH, was conducting a local flight training mission at the Aeroclube de Santa Catarina. The flight profile included maneuvers for takeoff, landing, and simulated engine failure at low altitude.
While climbing through approximately 700 feet on the downwind leg of the traffic pattern, witnesses observed the aircraft undergo a sudden, sharp pitch-up movement. This was immediately followed by a right-hand roll, leading to a loss of control and a collision with the ground at an angle of approximately 45 degrees. The impact resulted in the total loss of the aircraft. The student pilot on board was killed, and the instructor sustained serious injuries.
The investigation
CENIPA investigators examined the engine, magnetos, and fuel system, finding no evidence of internal engine failure or mechanical malfunction that would have caused a sudden loss of power. While some spark plugs showed significant electrode wear, this was not considered a factor in the crash.
The investigation focused on the operational execution of the simulated engine failure maneuver. Investigators analyzed the flight training program, the club's organizational structure, and the instructor's oversight. The investigation also reviewed the aerodrome's emergency capabilities and the club's adherence to regulatory standards.
Findings
- Improper Maneuver Execution: It is hypothesized that during the simulated engine failure, the pilot may have applied excessive back-pressure on the control column. This, combined with the reduction in power required for the exercise, likely induced an aerodynamic stall and a subsequent spin-like roll.
- Deficient Supervision: The flight training program was not in compliance with regulatory requirements (MMA 58-3). Student flight logs lacked clear, objective comments, making it difficult to monitor student progress effectively.
- Organizational Safety Deficiencies: The aeroclube exhibited a lack of a robust safety culture, characterized by poor interaction between the board of directors and flight instructors, and a lack of standardized instructor training.
- Operational Gaps: The aerodrome lacked an Aeronautical Emergency Plan, and the club lacked essential operational publications and updated accident prevention programs.