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
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
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