Transcript ORLANDO FSDO-15

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
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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
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ORLANDO FSDO
Flight Training
Accident & Incident
Analysis
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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
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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
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Student L.O.C.
14
19
5
15
20
4
Ratio
47 %
43 %
21 %
47 %
61 %
24 %
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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.
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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.
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PILOT SCHOOL RESPONSIBILITIES
Pilot School Special Emphasis Initiatives
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Pre-solo stage checks by senior instructors
Additional supervised solo operations
Enhanced dual cross-country training
Supervised solo at cross-country destinations
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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
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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
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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
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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”
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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
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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 LANDINGS
GEAR-UPS
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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
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SOLO STUDENT
1
1
3
1
1
1
1
1
3
2
1
14
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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)
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1
SOLO STUDENT
3
3
2
6
1
1
1
1
1
2
1
1
1
19
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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
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1
3
6
SOLO STUDENT
1
1
1
1
1
1
1
2
5
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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
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STUDENT & CFI
SOLO STUDENT
1
3
1
4
6
1
1
15
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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
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SOLO STUDENT
1
2
1
1
1
4
3
20
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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)
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1
2
1
2
1
2
0
SOLO STUDENT
1
1
2
4
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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 %
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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
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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
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Landing Events
20
30
16
25
27
9
4
Ratio
67 %
68 %
67 %
78 %
82 %
52 %
100 %
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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
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Opportunities for Improvement
Group Discussion
Recommendations
More PINK
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Opportunities for Improvement
More
Notices of Disapproval
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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
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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
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Opportunities for Improvement
Think PINK
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Additional Contributors to Orl FSDO
Flight Training Accidents & Incidents
Other Aircraft Flight Training & Testing
Gliders
Helicopters
Accident / Incident Review
January 24, 2013
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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
2
3
0
18
Ratio
17 %
7%
8%
9%
6%
18 %
0%
10 %
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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
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Additional Helicopter Information
Helicopter Examiner NVG Authorization
New Helicopter Flying Handbook
Steve Weaver
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AIRWORTHINESS INITIATIVE
The Orlando FSDO continues to place
special emphasis on the airworthiness
compliance of flight training aircraft.
Inspections
Analysis of Data
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FY 2012 MECHANICALLY CAUSED ACCIDENT
& INCIDENT DETAILED SUMMARY
OCCURRENCE
1
1
1
1
1
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
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
Engine failure
Engine failure
Voltage reg. failure
Gear trunion failure
Improper maint.
Improper maint.
Drag link bolt failure
Gear component fail.
Latch design
Carb. flooding
Overheated brakes
Undetermined
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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
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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
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