Covering form of preliminary or final report
| Date of event : | 2019-06-03 |
| Incident number : | CZ-19-0385 |
| Report : | Final report |
| Place of event : | LKLT |
| Registration mark : | Accident |
| Weight category MTOM: : | <2250 kg |
| Type of operation : | Recreational and sport aviation |
| Plane / SFM : | Airplanes |
| Type of plane / SFM : | Cessna 152 |
| Health effects of event : | Without injury |
| PDF document : | 
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Description:
SUMMARY
Synopsis
On 3 June 2019, the AAII was notified of an air accident of the Cessna 152 aircraft, registration mark OK-SUP, during landing on LKLT RWY 05. Having been tested by an instructor, the student pilot carried out his first solo flight on the circuit. During a go-around procedure, the aircraft hard landed on the RWY, the front landing gear leg collapsed, and the engine was shut down forcibly. The operating airport personnel assisted the pilot with disembarking the aircraft, and the summoned ERS brought him for a check-up in hospital. As a result of the air accident, the aircraft was damaged heavily. The pilot was not hurt.
An inspector from the AAII arrived at the AA site and began investigating the occurrence. Photographic documentation was taken, fuel sample was collected, and witnesses were examined. Video footage from the camera capturing the airport area and pilot’s communication with the AFIS controller were downloaded. Pilot’s statement was compared with documentary evidence, and consultation with the Safety Manager of the training organisation was initiated.
Analyses
The pilot was trained all the time at LKLT and that is why a decision was made to test him here. The resulting investigation revealed that instructors had to increase the number of pilot’s training hours by more than 15 hours due to his persistent errors. Over the training period, the student pilot’s merit rating was assessed as average and, in some aspects, as below the average. Individual flight training tasks lasted longer than stipulated by the syllabus as they had to be repeated due to recurring errors. During training flights, instructors focused on the elimination of errors pertaining to high flare, aircraft floating before landing, adherence to approach speed values, communication on a circuit, circuit shape, and tasks during a flight on a circuit. By following the correct training methodology and procedures, instructors were attempting to teach the student pilot how to prepare and observe a correct calculation of landing parameters. According to the instructor, the student pilot was aware of his errors and was trying to correct them during following flights. Thanks to his strong motivation and personal attitude, the student pilot convinced the instructor to provide him with some extra training flights in order to eliminate his major errors. Unsuccessful landings and their corrections were simulated. Landings focused on eliminating a high flare tendency, bouncing, and higher speed during floating . The total amount of 35 hours exceeded the average number of hours flown by a student pilot during training by approx. 15 hours. The overall practical training was performed at LKLT where the student pilot gained all his flight experience. This is why the LKLT was also chosen for his first solo flight and further advanced training. Four instructors were involved in the pilot’s training. The pilot in training failed the practical test criteria twice prior to his first solo flight while the pilot’s theoretical knowledge reached the required level. The pilot was strongly motivated to complete the training. While the pilot’s training results had not been consistently improving, the instructor did not find any critical errors or obstacles during the pilot’s final practical pre-test that would have led him not to authorise the pilot’s first solo flight.
The weather had no impact on occurrence and course of the air accident. The aircraft was properly serviced and had no effect on the occurrence of the AA. Witness’ statements and video recording confirmed the approach at a higher altitude and speed and the pilot’s attempts at correcting the errors. Eventually, he decided to perform a go-around procedure. The aircraft hit the runway hard three times during the go-around procedure and the nose gear collapsed with a forced engine shutdown.
The investigation revealed a discrepancy between the actual configuration of the aircraft on landing (flaps in the 30° position) and the pilot’s perception, who thought he had set the flaps to the 20° position. Comparative flights were performed with the same type of aircraft, to investigate the behaviour of the aircraft around the lateral axis after a bounce after adding engine power in a go-around procedure with flaps set at 30°. The aircraft required the pilot to pull the control stick significantly to prevent the nose from dropping to the runway and impacting with the subsequent bounce.
Conclusions/Causes
The cause of the accident on the first solo flight was the lack of awareness of the actual configuration of the aircraft on landing and failure to master the go-around procedure. Despite the increased number of flight hours in training, the student failed to master the aforementioned piloting procedure.
Safety Recommendations
The AAII recommends CZ/ATO 14 to stipulate a maximum threshold for increasing the number of flight hours in practical training of a student pilot, after which an analysis of the student’s training success with an assessment of the demonstration of proficiency prior to the first solo flight is required.
The AAII recommends to CZ-ATO-14 that the approach to hazard identification and risk assessment be revised to link the maintained hazard list to the characteristics of the organisation’s operations.
The AAII recommends to the CAA, following the findings of the investigation of this event and of event CZ-21-0059, that more emphasis be placed on the content of documentation relating to hazard identification and risk management during surveillance activities. The documentation should focus on activities/hazards that arise from the organisation’s operations and may arise within the organisation’s operations.
Attached final report in PDF file is in original Czech language.