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Accident leads to systematic look at CFI proficiencyAccident leads to systematic look at CFI proficiency

In at least two-thirds of all GA accidents, the National Transportation Safety Board places the blame squarely on the pilot. Most of the rest are attributed either to some kind of mechanical problem or engines that quit for reasons that can’t be explained afterward. Occasionally air traffic controllers are also taken to task, and a few CFIs have been faulted for failing to pay enough attention to the flight planning done for student solos. A recent accident in Utah, though, led the NTSB to take the unusual step of publicly criticizing the safety programs of the flight school that operated the aircraft—and not just any flight school, but a university program with some 250 active students.

Early in the afternoon of Nov. 17, 2010, a Diamond DA20-C1 crashed into a residential neighborhood in Payson, Utah, killing the 34-year-old instructor and 25-year-old student pilot. Witnesses described the airplane as “spinning” or “spiraling” to the ground “making numerous rotations;” investigators estimated the angle of impact as 44 degrees nose-down. The flight had been intended to help the student prepare for the last stage check prior to his private pilot checkride, and the plan was to practice slow flight, stalls, and landings. The NTSB concluded that the pilots had allowed the airplane to enter an unintended spin, and attributed the crash chiefly to “the flight instructor’s delayed or improper remedial actions to recover.”

Her failure to recover is puzzling, since the DA20 is approved for spins and the recovery procedure is conventional (power to idle, full opposite rudder, and forward stick until the spin stops, then neutralize the rudder and gradually raise the nose). Diamond provided the NTSB with the results of their spin tests, conducted at full aft CG and various flap positions. After 150 trials, they concluded that, “It is impossible to obtain an unrecoverable spin with any use of the controls at entry to or during the spin.”  Moreover, another student recalled that on a flight with the same instructor two weeks earlier, they had accidentally entered a spin while recovering from slow flight. The instructor had been able to recover in just one turn.

Why she was unable to do so this time hasn’t been explained. It’s possible, of course, that the student (who outweighed her by 30 pounds) froze on the controls. Other instructors also noted that shoes had been known to get jammed between the rudder cables, though only one said she’d had to unbuckle the shoe and pull her foot out to get it free. Reaching it required unlatching the four-point safety harness, and first responders found the instructor’s harness unbuckled, but that doesn’t prove she’d opened it deliberately. Several of the school’s instructors reported having seen harnesses come unbuckled during flight—something Diamond flatly denies any other operator has reported. Both bodies showed similar patterns of injuries and skin discolorations at autopsy, suggesting it could have opened during or after impact.

The instructor was a graduate of the same program. She’d had no spin training since receiving her original endorsement as a CFI candidate back in 2003 and of course wouldn’t have been expected to; recurrent spin training is neither required nor, we’d guess, common. School procedures did require instructors to pass annual evaluations on the curricula they taught, but this rarely amounted to more than a one-hour flight with the chief instructor of that program (private, instrument, commercial/multi-engine, or CFI).

More disturbing was that CFIs were not encouraged to make regular proficiency flights between those annual checks. Instructors were nominally entitled to up to one hour’s use of school aircraft per month, but this policy was not stated in the school’s policies and procedures manual and doesn’t appear to have been widely followed; billing records showed that instructors in the private pilot program made only about 40 percent as many proficiency flights as the policy allowed. Instructors wanting additional training to shore up any weaknesses had to seek it at their own expense. Worse, three of the four chief flight instructors felt that the director of operations actively discouraged CFI proficiency flights; one said he even questioned instructor use of the school’s simulators. The NTSB also criticized the lack of any system for tracking “mishaps or close calls” or facility for anonymously reporting safety concerns, and noted that the safety director was unaware of the instructors’ monthly proficiency allowance.

To its credit, the school took positive steps in response to the accident and investigation, beginning with a complete safety standdown and program review, an independent safety audit by an outside agency, and internal reorganizations to improve program oversight. CFIs received “additional spin awareness training.”

Other operators can take a few lessons from this tragedy. Chief among them is that keeping your instructors’ own airmanship sharp is a good investment, well worth a few hours’ Hobbs time (especially when the aircraft wouldn’t otherwise be flying). The best use of that time is probably to expand or sharpen critical skills that aren’t often used in daily training. Things such as instrument approaches, emergency procedures, and unusual attitude recoveries. And if your school operates a suitable airplane, regular practice on spin recoveries is probably not a bad idea.

ASI Staff

David Jack Kenny

Manager, Safety Analysis
David Jack Kenny analyzes GA accident data to target ASI’s safety education programs while also supporting AOPA’s ongoing initiatives and assisting other departments in responding to breaking developments. David maintains ASI’s accident database and regularly writes articles for ePilot, Flight School Business, Flight Training, CFI-to-CFI, and other publications.

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