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Accident / Incident Review

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Accident Incident Review

Accident Incident Review

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  • 1. Presented to: By: Date: Federal Aviation Administration Orlando Flight Standards District Office Accident / Incident Review CFI Special Emphasis Program Larry Enlow May 28, 2014
  • 2. Federal Aviation Administration 2 Accident / Incident Review May 28, 2014 ORLANDO FSDOORLANDO FSDO Flight Training Accident & Incident Analysis
  • 3. Federal Aviation Administration 3 Accident / Incident Review May 28, 2014 ACCIDENT & INCIDENT ANALYSISACCIDENT & INCIDENT ANALYSIS The Orlando FSDO has carefully analyzed 422 flight training accidents & incidents occurring within the district since the beginning of FY 1999 to determine: Causal Factors Trends Training Deficiencies Airworthiness Issues
  • 4. Federal Aviation Administration 4 Accident / Incident Review May 28, 2014 ORLANDO FSDO ACCIDENT & INCIDENT SUMMARY FLIGHT TRAINING ACCIDENTS & INCIDENTS 1998 1999 2000 2001 2002 2003 2004 60 38 24 28 22 18 12 2005 2006 2007 2008 2009 2010 2011 18 25 30 44 24 32 33 2012 2013 2014 17 17 18*
  • 5. Federal Aviation Administration 5 Accident / Incident Review May 28, 2014 FY 2007 ACCIDENT & INCIDENT DETAILEDFY 2007 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 GO AROUND (single eng.) 1 HELO HOVER 3 HELO SLOPE LND 1 HELO AUTOROTATION 1 1 WAKE TURBULENCE 1 FUEL EXHAUSTION 1 GEAR-UP 3 HARD LANDING (180 accu. lnd.) 1 LANDING (loss of control) 2 14
  • 6. Federal Aviation Administration 6 Accident / Incident Review May 28, 2014 FY 2008 ACCIDENT & INCIDENT DETAILEDFY 2008 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 3 HELO HARD LANDING 1 HELO AUTOROTATION 1 HELO GROUND VIBRATION 1 UNLATCHED CANOPY / DOOR 1 1 SR-20 BRAKE FIRE 1 LOSS OF POWER (water in fuel) 1 TAKEOFF 3 GEAR DOWN WATER LANDING 1 GEAR-UP 6 HARD LANDING 2 LANDING (loss of control) 2 19
  • 7. Federal Aviation Administration 7 Accident / Incident Review May 28, 2014 FY 2009 ACCIDENT & INCIDENT DETAILEDFY 2009 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 1 HELO (dynamic rollover) 1 HELO (hard landing) 1 FUEL EXHAUSTION 1 STALL / SPIN 1 TAKEOFF (loss of control) 1 GLIDER (off airport landing) 1 GEAR-UP 6 HARD LANDING 3 LANDING (loss of control) 2 5
  • 8. Federal Aviation Administration 8 Accident / Incident Review May 28, 2014 FY 2010 ACCIDENT & INCIDENT DETAILEDFY 2010 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 HELO (hard landing) 3 FUEL MISMANAGEMENT 1 1 TAKEOFF (loss of control) 1 GEAR-UP 4 LANDING (loss of control) 6 15
  • 9. Federal Aviation Administration 9 Accident / Incident Review May 28, 2014 FY 2011 ACCIDENT & INCIDENT DETAILEDFY 2011 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 STALL / SPIN 2 FUEL EXHAUSTION 1 HELICOPTER AUTOROTATION 1 HELICOPTER GRASS FIRE 1 GEAR-UP 4 LANDING (loss of control) 3 20
  • 10. Federal Aviation Administration 10 Accident / Incident Review May 28, 2014 FY 2012 ACCIDENT & INCIDENT DETAILEDFY 2012 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 1 HELICOPTER HARD LANDING 2 HELICOPTER DYNAM. ROLL. 1 ENGINE FIRE 1 ABORTED TAKEOFF 2 GEAR-UP 2 1 HARD LANDING 2 LANDING (loss of control) 4
  • 11. Federal Aviation Administration 11 Accident / Incident Review May 28, 2014 FY 2013 ACCIDENT & INCIDENT DETAILEDFY 2013 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GROUND 4 PA-28 ENGINE FIRE 1 TAKEOFF (loss of control) 2 GEAR-UP 1 HARD LANDING 1* 4 * during practical test LANDING (loss of control) 1 3
  • 12. Federal Aviation Administration 12 Accident / Incident Review May 28, 2014 FY 2014FY 2014** ACCIDENT & INCIDENT DETAILEDACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GROUND 1 LOST DOOR IN FLIGHT 1 GEAR-UP 2 GEAR-DOWN WATER LANDING 1 HARD LANDING 4 3 HELO HARD LANDING 1 LANDING (loss of control) 1 3 GLIDER LANDING (hit building) 1 * 05-27-2014
  • 13. Federal Aviation Administration 13 Accident / Incident Review May 28, 2014 Orlando FSDO Flight Training Accidents &Orlando FSDO Flight Training Accidents & Incidents Involving LandingsIncidents Involving Landings Student & CFI hard landings, gear-ups, & loss of control Year Total Events Landing Events Ratio 2007 30 20 67 % 2008 44 30 68 % 2009 24 16 67 % 2010 32 25 78 % 2011 33 27 82 % 2012 17 9 52 % 2013 17 10 58 % 2014* 18 16 89 % 215 153 71 %
  • 14. Federal Aviation Administration 14 Accident / Incident Review May 28, 2014 Opportunities for ImprovementOpportunities for Improvement Significant improvement has been made as Pilot Schools, Check Instructors, and Pilot Examiners place special emphasis on landings But 71 % of our district’s flight training accidents and incidents are still due to landing mishaps. Maintain landing special emphasis initiative
  • 15. Federal Aviation Administration 15 Accident / Incident Review May 28, 2014 PILOT SCHOOL RESPONSIBILITIESPILOT SCHOOL RESPONSIBILITIES Pilot School Special Emphasis Initiatives • Pre-solo stage checks by senior instructors • Additional supervised solo operations • Enhanced dual cross-country training • Supervised solo at cross-country destinations
  • 16. Federal Aviation Administration 16 Accident / Incident Review May 28, 2014 FLIGHT INSTRUCTOR STUDENT SOLOFLIGHT INSTRUCTOR STUDENT SOLO RESPONSIBILIESRESPONSIBILIES In order to solo, a student must be able to: • Make competent go / no-go decisions for every flight • Determine the location of all other traffic while in the pattern • Establish and maintain a stabilized approach • Determine wind direction and make proper control inputs • Manage energy so landings occur at the touchdown point • Land with and maintain proper pitch attitude • Keep the longitudinal axis parallel to and over the centerline • Keep the centerline between the main wheels during landing • Correctly respond to any abnormality or emergency • Communicate properly & effectively with other traffic or ATC
  • 17. Federal Aviation Administration 17 Accident / Incident Review May 28, 2014 FLIGHT INSTRUCTOR STUDENT SOLOFLIGHT INSTRUCTOR STUDENT SOLO RESPONSIBILIESRESPONSIBILIES If a student cannot perform the “solo checklist ” functions without guidance or assistance from the flight instructor, then the student is not ready to solo
  • 18. Federal Aviation Administration 18 Accident / Incident Review May 28, 2014 EVALUATOR RESPONSIBILITYEVALUATOR RESPONSIBILITY If a student cannot perform the functions of the “Solo Checklist ” during a stage check, end-of- course test, or practical test, then the student’s performance is unsatisfactory All 10 items on the “Solo Checklist” are supported by the applicable PTS and Airplane Flying Handbook
  • 19. Federal Aviation Administration 19 Accident / Incident Review May 28, 2014 Opportunities for ImprovementOpportunities for Improvement Special Emphasis Initiatives • Place increased emphasis upon landings and gear operation during stage checks and end-of-course tests. • Place significant emphasis upon proper instructional techniques and demonstration of landings and gear operations during flight instructor checks and tests. • Develop scenario based questions applicable to landing gear system malfunctions. • Test flight instructor “student error” intervention associated with landings and landing gear operations. • Strictly apply PTS, “solo checklist”, and Airplane Flying Handbook guidelines.
  • 20. Federal Aviation Administration 20 Accident / Incident Review May 28, 2014 Additional Evaluator ResponsibilityAdditional Evaluator Responsibility Identify Training Deficiencies Observe applicant’s seat position Eye Level Position of Feet on Rudders Observe touchdown control movements Proper Aileron Input for Crosswind Elevator “Follow-through” Automobile Driving “Negative Transfer”
  • 21. Federal Aviation Administration 21 Accident / Incident Review May 28, 2014 Identify Training DeficienciesIdentify Training Deficiencies “The eye can’t see what the mind does not know” Upon completion of testing, Evaluators should de-brief all Students and their Flight Instructors regarding Training Deficiencies Evaluators must assure that accurate communication with the Student and Flight Instructor has been accomplished
  • 22. Federal Aviation Administration 22 Accident / Incident Review May 28, 2014 Additional Contributors to Orl FSDOAdditional Contributors to Orl FSDO Flight Training Accidents & IncidentsFlight Training Accidents & Incidents Other Aircraft Flight Training & Testing Gliders Helicopters
  • 23. Federal Aviation Administration 23 Accident / Incident Review May 28, 2014 Additional Contributors to Orl FSDOAdditional Contributors to Orl FSDO Flight Training Accidents & IncidentsFlight Training Accidents & Incidents Glider Events 2009 Off-airport landing with CFI aboard 2014 Student pilot hit building during landing
  • 24. Federal Aviation Administration 24 Accident / Incident Review May 28, 2014 Additional Contributors to Orl FSDOAdditional Contributors to Orl FSDO Flight Training Accidents & IncidentsFlight Training Accidents & Incidents Helicopter Hard Landing, Hover, and Autorotation Events Year Total Events Helo Events Ratio 2007 30 5 17 % 2008 44 3 7 % 2009 24 2 8 % 2010 32 3 9 % 2011 33 2 6 % 2012 17 3 18 % 2013 17 0 0 % 2014 18 1 5 % 215 19 8 %
  • 25. Federal Aviation Administration 25 Accident / Incident Review May 28, 2014 Opportunities for ImprovementOpportunities for Improvement Helicopter Special Emphasis Initiatives • Place increased emphasis upon hover operations, landings and autorotations during all tests. • Place significant emphasis upon proper instructional techniques and demonstration of hover operations, landings and autorotations during flight instructor tests. • Develop scenario based questions applicable to helicopter system or component malfunctions. • Test flight instructor “student error” intervention associated with hover operations, vertical takeoffs & landings (pick-ups & set-downs) and autorotations.
  • 26. Federal Aviation Administration 26 Accident / Incident Review May 28, 2014 Pilot Deviation Special EmphasisPilot Deviation Special Emphasis Special emphasis needed to reduce the number of pilot deviations occurring during flight training • Use of airport diagrams for all surface operations • Modify method of conducting take-off briefing • Improve ATC listening skills with less talk in the cockpit • Emphasize situational and positional awareness during all flight training operations
  • 27. Presented to: By: Date: Federal Aviation Administration Orlando Flight Standards District Office Mechanically Caused Accident / Incident Review 141 / 142 Safety Summit Larry Enlow May 28, 2014
  • 28. Federal Aviation Administration 28 Accident / Incident Review May 28, 2014 AIRWORTHINESS INITIATIVEAIRWORTHINESS INITIATIVE The Orlando FSDO continues to place special emphasis on the airworthiness compliance of flight training aircraft. Inspections Analysis of Data
  • 29. Federal Aviation Administration 29 Accident / Incident Review May 28, 2014 FY 2012 MECHANICALLY CAUSED ACCIDENTFY 2012 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY& INCIDENT DETAILED SUMMARY OCCURRENCE CAUSE 1 SR-20 emer. landing on road Engine failure 1 CE-172 emer. landing in field Engine failure 1 HU-269 emer. autorotation into field Engine failure 1 CE-172 smoke in cockpit Voltage reg. failure 1 CE-172 RG right gear collapse Gear trunion failure 1 BE-76 nose gear jammed Improper maint. 1 PA-44 nose gear collapse Improper maint. 1 PA-44 nose gear collapse Drag link bolt failure 1 Light Sport nose gear collapse Gear component fail. 1 CE-162 door opened in flight Latch design 4 PA-28 engine fires while starting Carb. flooding 1 SR-20 brake failure Overheated brakes 1 PA-28 propeller blade broke off Undetermined
  • 30. Federal Aviation Administration 30 Accident / Incident Review May 28, 2014 FY 2013 MECHANICALLY CAUSED ACCIDENTFY 2013 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY& INCIDENT DETAILED SUMMARY OCCURRENCE CAUSE 1 UC-1 left brake failure Loss of brake fluid 1 PA-34 smoke in cockpit Panel light control 1 PA-28R loss of power Fuel inject. system 1 PA-44 right main gear collapse Locking bracket fail. 1 CE-172RG left main gear collapse Gear strut pin failure 1 CE-172 emer. land. (oil on windshield) Engine case crack 1 HU-269 emergency autorotation Engine failure 1 PA-34 rudder trim tab control rod failure Corrosion
  • 31. Federal Aviation Administration 31 Accident / Incident Review May 28, 2014 FY 2014 MECHANICALLY CAUSED ACCIDENTFY 2014 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY& INCIDENT DETAILED SUMMARY OCCURRENCE CAUSE 1 SR-20 left brake failure Brake cylinder fail 1 PA-44 left main gear collapse Trunnion attach. fail. 1 CE-182RG nose gear collapse Locking pin failure 1 HU-269 emergency autorotation Undetermined 1 Weight Shift lost power on takeoff Undetermined 1 BE-76 nose gear collapse Gear door rod bent 1 PA-28R engine failure Loss of oil pressure 2 PA-28 engine fires while starting Carb. flooding