orlando flight standards district office

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Federal AviationAdministration

Orlando Flight Standards District Office

Accident / Incident Review

Orlando FSDO Pilot Examiners

Larry Enlow

January 24, 2013

Federal AviationAdministration 2Accident / Incident Review

January 24, 2013

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 FactorsTrends

Training Deficiencies


January 24, 2013

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


January 24, 2013

ORLANDO FSDO

Flight TrainingAccident & Incident

Analysis


January 24, 2013

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 17


January 24, 2013

Major Contributor to 2012 Event Reduction

Less Student Pilot Loss of Control During Landing Events

Year Total Events Student L.O.C. Ratio

2007 30 14 47 % 2008 44 19 43 % 2009 24 5 21 % 2010 32 15 47 % 2011 33 20 61 % 2012 17 4 24 %


January 24, 2013

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.


January 24, 2013

EXAMINER RESPONSIBILITIES

Examiner Special Emphasis Initiatives

• Place increased emphasis upon landings and go- arounds during practical tests at all certificate levels.

• Place significant emphasis upon proper instructional techniques and demonstration of landings and go-arounds 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.


January 24, 2013

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


January 24, 2013

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


January 24, 2013

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


January 24, 2013

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


January 24, 2013

Additional Examiner ResponsibilityIdentify Training Deficiencies

Observe applicant’s seat positionEye Level

Position of Feet on Rudders

Observe touchdown control movementsProper Aileron Input for Crosswind

Elevator “Follow-through”Automobile Driving “Negative Transfer”


January 24, 2013

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


January 24, 2013

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 CFI with Student

HARD LANDINGSGEAR-UPS


January 24, 2013

FY 2007 ACCIDENT & INCIDENT DETAILED SUMMARY

OCCURRENCE STUDENT & CFI SOLO STUDENT

COLLISION ON GND 1GO AROUND (single eng.) 1 HELO HOVER 3HELO SLOPE LND 1HELO AUTOROTATION 1 1WAKE TURBULENCE 1FUEL EXHAUSTION 1 HARD LANDING (180 accu. lnd.) 1GEAR-UP 3LANDING (loss of control) 2 14


January 24, 2013



COLLISION ON GND 1 3TAKEOFF 3HARD LANDING 2GEAR-UP 6GEAR DOWN WATER LANDING 1HELO HARD LANDING 1HELO AUTOROTATION 1HELO GROUND VIBRATION 1UNLATCHED CANOPY / DOOR 1 1SR-20 BRAKE FIRE 1WATER IN FUEL 1LANDING (loss of control) 2 19


January 24, 2013



COLLISION ON GND 1 1HARD LANDING 3GEAR-UP 6HELO (dynamic rollover) 1HELO (hard landing) 1FUEL EXHAUSTION 1STALL / SPIN 1TAKEOFF (loss of control) 1GLIDER (off airport landing) 1LANDING (loss of control) 2 5


January 24, 2013



COLLISION ON GND 1HELO (hard landing) 3FUEL MISMANAGEMENT 1 1 GEAR-UP 4TAKEOFF (loss of control) 1LANDING (loss of control) 6 15


January 24, 2013



COLLISION ON GND 1STALL / SPIN 2FUEL EXHAUSTION 1HELICOPTER AUTOROTATION 1HELICOPTER GRASS FIRE 1GEAR-UP 4 LANDING (loss of control) 3 20


January 24, 2013



COLLISION ON GND 1 1HELICOPTER HARD LANDING 2HELICOPTER DYNAM. ROLL. 1GEAR-UP 2 1ENGINE FIRE 1HARD LANDING 2ABORTED TAKEOFF 2LANDING (loss of control) 0 4


January 24, 2013


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 %


January 24, 2013



GEAR-UP 1HARD LANDING 1*

* during practical testLANDING (loss of control) 0 2


January 24, 2013


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 %


January 24, 2013

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.


January 24, 2013


Group Discussion

Recommendations

More PINK


January 24, 2013


More

Notices of Disapproval


January 24, 2013

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 %


January 24, 2013


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


January 24, 2013


Think PINK


January 24, 2013

Additional Contributors to Orl FSDO Flight Training Accidents & Incidents

Other Aircraft Flight Training & Testing

Gliders

Helicopters


January 24, 2013

Additional Contributors to Orl FSDO Flight 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 4 0 0 %

184 18 10 %


January 24, 2013


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.


January 24, 2013

Additional Helicopter Information

Helicopter Examiner NVG Authorization

New Helicopter Flying Handbook

Steve Weaver


January 24, 2013

AIRWORTHINESS INITIATIVE

The Orlando FSDO continues to place special emphasis on the airworthiness compliance of flight training aircraft.

InspectionsAnalysis of Data


January 24, 2013

FY 2012 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY

OCCURRENCE CAUSE

1 SR-20 emer. landing on road Engine failure1 CE-172 emer. landing in field Engine failure1 HU-269 emer. autorotation into field Engine failure1 CE-172 smoke in cockpit Voltage reg. failure1 CE-172 RG right gear collapse Gear trunion failure1 BE-76 nose gear jammed Improper maint.1 PA-44 nose gear collapse Improper maint.1 PA-44 nose gear collapse Drag link bolt failure1 Light Sport nose gear collapse Gear component fail.1 CE-162 door opened in flight Latch design4 PA-28 engine fires while starting Carb. flooding 1 SR-20 brake failure Overheated

brakes1 PA-28 propeller blade broke off Undetermined


January 24, 2013

FY 2013 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY

OCCURRENCE CAUSE

1 Loss of control during taxi while turning Loss of brake pressure


January 24, 2013

AIRWORTHINESS INITIATIVE

New initiative to improve Airworthiness Compliance of Pilot Schools operating Flight Training Aircraft

Airworthiness Designee Focal Point

Joe Gramzinski

DPE Airworthiness LiaisonPete Kandravi

orlando flight standards district office

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