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Systemic failuresSystemic failures

Most accidents during primary flight training result from momentary lapses in aircraft handling, and some risk of that is inherent in the process. On dual flights, students must be given chances to make mistakes in order to learn. Knowing exactly when to intervene is more art than science. Solo flights by student pilots are structured to leave as little as possible to chance, but enough solos flown by enough students will inevitably result in occasional encounters with the unexpected. Equally inevitably, some will be handled better than others.

Now and again, however, an accident reveals systemic deficiencies in the program that produced it. One example was the September 2012 case of controlled flight into terrain that killed a student pilot, a substitute instructor, and an evaluator employed by the foreign airline sponsoring the student. The sponsor’s insistence on having all training conducted below 1,500 feet agl led them to fly a Piper Archer into a blind canyon on a cross-country stage check.

Another was the fatal crash of a Diamond DA20 following an inadvertent spin while practicing slow flight and stalls. The instructor had allowed another student to put the airplane into a spin just two weeks earlier but recovered quickly; why she was unable to recover on the accident flight has never been explained. Both accidents prompted the schools involved to revise their procedures to address underlying flaws that had previously gone undetected.

While the official determination of probable cause may not be released for a year or more, there are strong early indications that an accident in Georgia on October 8, 2015, will fall into the same category. A 21-year-old 13.5-hour student pilot signed out a Piper Tomahawk for his second solo flight. After about an hour in the practice area, he returned to his home airport and did a touch-and-go; according to a witness, the Tomahawk’s engine stopped as it was climbing out. The pilot began a left turn in an apparent attempt to return to the airport, only to stall and spin into the ground.

The reason for the engine stoppage already seems clear: According to the preliminary report, "The fuel strainer was devoid of fuel….a negligible amount of fuel was present in the left fuel tank, and approximately a � cup [sic] of fuel was present in the right tank.": A "time sheet": found in the wreckage showed that the airplane had last been refueled three days earlier. Including the accident flight, it had been flown five times since for a total of 4.9 hours—more than enough to exhaust its full capacity of 30 usable gallons.

Knowing that somehow a student pilot was allowed to taxi out with barely an hour’s worth of fuel might prompt you to take a fresh look at the safeguards built into your own operation. Questions worth asking include:

  • Who’s responsible for ensuring that your aircraft have sufficient fuel before they’re dispatched? Are flight times checked against fueling records?
  • Does the answer depend on who’ll be pilot in command? In particular, does anyone cross-check fuel quantities and requirements for local student solos?
  • Have you set model-specific limits on the number of hours that may be flown before refueling is required?
  • How do you assure that students do a thorough and meaningful preflight—and actually understand what they see?
  • Do your instructors show their students the likeliest emergency landing sites off the end of each runway in case of engine failures during climbout?

The compulsion to turn back toward the airport after an engine quits has overwhelmed experienced professionals, often to dire effect. Impressing your students with the inadvisability of trying it at low altitude—and the vital importance of maintaining airspeed and coordination as the aircraft nears the ground—can hardly begin too early in training or be repeated too emphatically. Of course, minimizing the chance of an engine stoppage in the first place is at least as important.

We noted earlier that a risk of certain types of accidents is an intrinsic part of the training process. Others are utterly avoidable. When they happen anyway, despite repeated chances to avoid them, it’s time to ask what can be done to make certain the same things can’t happen at your flight school.

David Jack Kenny is manager of safety analysis for the AOPA Air Safety Institute.

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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