Orlando Flight Standards District Office Accident Incident Review

Orlando Flight Standards District Office Accident / Incident Review Presented to: Orlando FSDO Pilot Examiners By: Larry Enlow Date: January 24, 2013 Federal Aviation Administration

ACCIDENT & INCIDENT ANALYSIS The Orlando FSDO has carefully analyzed 386 flight training accidents & incidents occurring within the district since the beginning of FY 1999 to determine: Causal Factors Trends Training Deficiencies Accident / Incident Review January 24, 2013 Federal Aviation Administration 2

ACCIDENT & INCIDENT ANALYSIS Accident & Incident analysis provides valuable information for determining flight training risks and subsequent development of special emphasis areas to mitigate risks. SAFETY MANAGEMENT SYSTEM Accident / Incident Review January 24, 2013 Federal Aviation Administration 3

ORLANDO FSDO Flight Training Accident & Incident Analysis Accident / Incident Review January 24, 2013 Federal Aviation Administration 4

ORLANDO FSDO ACCIDENT & INCIDENT SUMMARY FLIGHT TRAINING ACCIDENTS & INCIDENTS 1998 60 1999 38 2000 24 2001 28 2002 22 2003 18 2004 12 2005 18 2006 25 2007 30 2008 44 2009 24 2010 32 2011 33 2012 17 Accident / Incident Review January 24, 2013 Federal Aviation Administration 5

Major Contributor to 2012 Event Reduction Less Student Pilot Loss of Control During Landing Events Year Total Events 2007 2008 2009 2010 2011 2012 30 44 24 32 33 17 Accident / Incident Review January 24, 2013 Student L. O. C. 14 19 5 15 20 4 Ratio 47 % 43 % 21 % 47 % 61 % 24 % Federal Aviation Administration 6

ORLANDO FSDO Orlando FSDO Inspectors, Pilot Examiners, and Pilot Schools have worked diligently to achieve a reduction in the number of landing accidents and incidents occurring during flight training within the District. Accident / Incident Review January 24, 2013 Federal Aviation Administration 7

EXAMINER RESPONSIBILITIES Examiner Special Emphasis Initiatives • Place increased emphasis upon landings and goarounds during practical tests at all certificate levels. • Place significant emphasis upon proper instructional techniques and demonstration of landings and goarounds during flight instructor practical tests. • Develop scenario based questions applicable to flight instructor responsibilities associated with supervising student solo flights. • Test flight instructor “student error” intervention. Accident / Incident Review January 24, 2013 Federal Aviation Administration 8

PILOT 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 Accident / Incident Review January 24, 2013 Federal Aviation Administration 9

FLIGHT INSTRUCTOR STUDENT SOLO RESPONSIBILIES 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 Accident / Incident Review January 24, 2013 Federal Aviation Administration 10

FLIGHT INSTRUCTOR STUDENT SOLO RESPONSIBILIES 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 Accident / Incident Review January 24, 2013 Federal Aviation Administration 11

EXAMINER RESPONSIBILITY If an applicant cannot perform the functions of the “Solo Checklist ” during a practical test, then the applicant fails the test. All 10 items on the “Solo Checklist” are supported by the applicable PTS and Airplane Flying Handbook Accident / Incident Review January 24, 2013 Federal Aviation Administration 12

Additional Examiner 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” Accident / Incident Review January 24, 2013 Federal Aviation Administration 13

Identify Training Deficiencies “The eye can’t see what the mind does not know” De-brief all Applicants and their Recommending Flight Instructors regarding Training Deficiencies Accident / Incident Review January 24, 2013 Federal Aviation Administration 14

Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Discussion focused on Student Loss of Control during Landing Rollout Add to discussion Student Solo or with Student CFI HARD LANDINGS GEAR-UPS Accident / Incident Review January 24, 2013 Federal Aviation Administration 15

FY 2007 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFI COLLISION ON GND GO AROUND (single eng. ) HELO HOVER HELO SLOPE LND HELO AUTOROTATION WAKE TURBULENCE FUEL EXHAUSTION HARD LANDING (180 accu. lnd. ) GEAR-UP LANDING (loss of control) Accident / Incident Review January 24, 2013 SOLO STUDENT 1 1 3 1 1 1 3 2 1 14 Federal Aviation Administration 16

FY 2008 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFI COLLISION ON GND TAKEOFF HARD LANDING GEAR-UP GEAR DOWN WATER LANDING HELO HARD LANDING HELO AUTOROTATION HELO GROUND VIBRATION UNLATCHED CANOPY / DOOR SR-20 BRAKE FIRE WATER IN FUEL LANDING (loss of control) Accident / Incident Review January 24, 2013 1 SOLO STUDENT 3 3 2 6 1 1 1 2 1 19 Federal Aviation Administration 17

FY 2009 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFI COLLISION ON GND HARD LANDING GEAR-UP HELO (dynamic rollover) HELO (hard landing) FUEL EXHAUSTION STALL / SPIN TAKEOFF (loss of control) GLIDER (off airport landing) LANDING (loss of control) Accident / Incident Review January 24, 2013 1 3 6 SOLO STUDENT 1 1 1 1 2 5 Federal Aviation Administration 18

FY 2010 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE COLLISION ON GND HELO (hard landing) FUEL MISMANAGEMENT GEAR-UP TAKEOFF (loss of control) LANDING (loss of control) Accident / Incident Review January 24, 2013 STUDENT & CFI SOLO STUDENT 1 3 1 4 6 1 1 15 Federal Aviation Administration 19

FY 2011 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFI COLLISION ON GND STALL / SPIN FUEL EXHAUSTION HELICOPTER AUTOROTATION HELICOPTER GRASS FIRE GEAR-UP LANDING (loss of control) Accident / Incident Review January 24, 2013 SOLO STUDENT 1 2 1 1 1 4 3 20 Federal Aviation Administration 20

FY 2012 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFI COLLISION ON GND HELICOPTER HARD LANDING HELICOPTER DYNAM. ROLL. GEAR-UP ENGINE FIRE HARD LANDING ABORTED TAKEOFF LANDING (loss of control) Accident / Incident Review January 24, 2013 1 2 1 2 0 SOLO STUDENT 1 1 2 4 Federal Aviation Administration 21

Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Student & CFI hard landings, gear-ups, & loss of control Year Total Events 2007 2008 2009 2010 2011 2012 30 44 24 32 33 17 Accident / Incident Review January 24, 2013 Landing Events 20 30 16 25 27 9 Ratio 67 % 68 % 67 % 78 % 82 % 52 % Federal Aviation Administration 22

FY 2013 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE GEAR-UP HARD LANDING * during practical test LANDING (loss of control) Accident / Incident Review January 24, 2013 STUDENT & CFI SOLO STUDENT 1 1* 0 2 Federal Aviation Administration 23

Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Student & CFI hard landings, gear-ups, & loss of control Year Total Events 2007 2008 2009 2010 2011 2012 2013 30 44 24 32 33 17 4 Accident / Incident Review January 24, 2013 Landing Events 20 30 16 25 27 9 4 Ratio 67 % 68 % 67 % 78 % 82 % 52 % 100 % Federal Aviation Administration 24

Opportunities for Improvement Examiner Special Emphasis Initiatives • Place increased emphasis upon landings and gear operation during practical tests at all certificate levels. • Place significant emphasis upon proper instructional techniques and demonstration of landings and gear operations during flight instructor practical tests. • Develop scenario based questions applicable to landing gear system malfunctions. • Test flight instructor “student error” intervention associated with landings and landing gear operations. Accident / Incident Review January 24, 2013 Federal Aviation Administration 25

Opportunities for Improvement Group Discussion Recommendations More PINK Accident / Incident Review January 24, 2013 Federal Aviation Administration 26

Opportunities for Improvement More Notices of Disapproval Accident / Incident Review January 24, 2013 Federal Aviation Administration 27

Orlando FSDO Flight Training Accidents & Incidents 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 4 4 100 % 184 131 71 % Accident / Incident Review January 24, 2013 Federal Aviation Administration 28

Opportunities for Improvement Only 25 % of practical tests conducted by Orlando FSDO DPEs are failed due to unsatisfactory landing tasks Discontinuity Strictly apply PTS, “Solo Checklist”, and Airplane Flying Handbook guidelines Accident / Incident Review January 24, 2013 Federal Aviation Administration 29

Opportunities for Improvement Think PINK Accident / Incident Review January 24, 2013 Federal Aviation Administration 30

Additional Contributors to Orl FSDO Flight Training Accidents & Incidents Other Aircraft Flight Training & Testing Gliders Helicopters Accident / Incident Review January 24, 2013 Federal Aviation Administration 31

Additional Contributors to Orl FSDO Flight Training Accidents & Incidents Helicopter Hard Landing, Hover, and Autorotation Events Year 2007 2008 2009 2010 2011 2012 2013 Accident / Incident Review January 24, 2013 Total Events 30 44 24 32 33 17 4 184 Helo Events 5 3 2 3 0 18 Ratio 17 % 7% 8% 9% 6% 18 % 0% 10 % Federal Aviation Administration 32

Opportunities for Improvement Helicopter Examiner Special Emphasis Initiatives • Place increased emphasis upon hover operations, landings and autorotations during all practical tests. • Place significant emphasis upon proper instructional techniques and demonstration of hover operations, landings and autorotations during flight instructor practical 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. Accident / Incident Review January 24, 2013 Federal Aviation Administration 33

Additional Helicopter Information Helicopter Examiner NVG Authorization New Helicopter Flying Handbook Steve Weaver Accident / Incident Review January 24, 2013 Federal Aviation Administration 34

AIRWORTHINESS INITIATIVE The Orlando FSDO continues to place special emphasis on the airworthiness compliance of flight training aircraft. Inspections Analysis of Data Accident / Incident Review January 24, 2013 Federal Aviation Administration 35

FY 2012 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE 1 1 1 1 1 4 1 1 SR-20 emer. landing on road CE-172 emer. landing in field HU-269 emer. autorotation into field CE-172 smoke in cockpit CE-172 RG right gear collapse BE-76 nose gear jammed PA-44 nose gear collapse Light Sport nose gear collapse CE-162 door opened in flight PA-28 engine fires while starting SR-20 brake failure PA-28 propeller blade broke off Accident / Incident Review January 24, 2013 CAUSE Engine failure Voltage reg. failure Gear trunion failure Improper maint. Drag link bolt failure Gear component fail. Latch design Carb. flooding Overheated brakes Undetermined Federal Aviation Administration 36

FY 2013 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE 1 Loss of control during taxi while turning Accident / Incident Review January 24, 2013 CAUSE Loss of brake pressure Federal Aviation Administration 37

AIRWORTHINESS INITIATIVE New initiative to improve Airworthiness Compliance of Pilot Schools operating Flight Training Aircraft Airworthiness Designee Focal Point Joe Gramzinski DPE Airworthiness Liaison Pete Kandravi Accident / Incident Review January 24, 2013 Federal Aviation Administration 38