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

Federal Aviation Administration 2 Accident / 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 Factors Trends Training Deficiencies

Federal Aviation Administration 3 Accident / Incident Review 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

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

Federal Aviation Administration 5 Accident / Incident Review January 24, 2013 ORLANDO FSDO ACCIDENT & INCIDENT SUMMARY FLIGHT TRAINING ACCIDENTS & INCIDENTS

Federal Aviation Administration 6 Accident / Incident Review 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 % % % % % %

Federal Aviation Administration 7 Accident / Incident Review 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.

Federal Aviation Administration 8 Accident / Incident Review 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.

Federal Aviation Administration 9 Accident / Incident Review 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

Federal Aviation Administration 10 Accident / Incident Review 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

Federal Aviation Administration 11 Accident / Incident Review 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

Federal Aviation Administration 12 Accident / Incident Review 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

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

Federal Aviation Administration 14 Accident / Incident Review 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

Federal Aviation Administration 15 Accident / Incident Review 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 LANDINGS GEAR-UPS

Federal Aviation Administration 16 Accident / Incident Review January 24, 2013 FY 2007 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFI SOLO STUDENT COLLISION ON GND 1 GO AROUND (single eng.) 1 HELO HOVER 3 HELO SLOPE LND 1 HELO AUTOROTATION 11 WAKE TURBULENCE 1 FUEL EXHAUSTION 1 HARD LANDING (180 accu. lnd.) 1 GEAR-UP 3 LANDING (loss of control) 2 14

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

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

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

Federal Aviation Administration 20 Accident / Incident Review January 24, 2013 FY 2011 ACCIDENT & INCIDENT DETAILED SUMMARY 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

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

Federal Aviation Administration 22 Accident / Incident Review January 24, 2013 Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Student & CFI hard landings, gear-ups, & loss of control Year Total Events Landing Events Ratio % % % % % %

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

Federal Aviation Administration 24 Accident / Incident Review January 24, 2013 Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Student & CFI hard landings, gear-ups, & loss of control Year Total Events Landing Events Ratio % % % % % % %

Federal Aviation Administration 25 Accident / Incident Review 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.

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

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

Federal Aviation Administration 28 Accident / Incident Review 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 % % % % % % % %

Federal Aviation Administration 29 Accident / Incident Review January 24, 2013 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

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

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

Federal Aviation Administration 32 Accident / Incident Review 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 % % % % % % % %

Federal Aviation Administration 33 Accident / Incident Review January 24, 2013 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.

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

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

Federal Aviation Administration 36 Accident / Incident Review January 24, 2013 FY 2012 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE CAUSE 1 SR-20 emer. landing on roadEngine failure 1 CE-172 emer. landing in fieldEngine failure 1 HU-269 emer. autorotation into fieldEngine failure 1 CE-172 smoke in cockpitVoltage 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 flightLatch design 4 PA-28 engine fires while starting Carb. flooding 1 SR-20 brake failureOverheated brakes 1 PA-28 propeller blade broke offUndetermined

Federal Aviation Administration 37 Accident / Incident Review 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

Federal Aviation Administration 38 Accident / Incident Review 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 Liaison Pete Kandravi