Orlando Flight Standards District Office

1. Orlando Flight Standards District Office Accident / Incident Review Orlando FSDO Pilot Examiners Larry Enlow January 24, 2013

2. 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

3. 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

4. ORLANDO FSDO Flight Training Accident & Incident Analysis

5. ORLANDO FSDO ACCIDENT & INCIDENT SUMMARY FLIGHT TRAINING ACCIDENTS & INCIDENTS 1998199920002001200220032004 60 38 24 28 22 18 12 2005200620072008200920102011 18 25 30 44 24 32 33 2012 17

6. Major Contributor to 2012 Event Reduction Less Student Pilot Loss of Control During Landing Events YearTotal EventsStudent 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 %

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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”

14. Identify Training Deficiencies “The eye can’t see what the mind does not know” De-brief all Applicantsand theirRecommendingFlight InstructorsregardingTraining Deficiencies

15. 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

16. FY 2007 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCESTUDENT & CFISOLO STUDENT COLLISION ON GND 1 GO AROUND (single eng.) 1 HELO HOVER 3 HELO SLOPE LND 1 HELO AUTOROTATION 1 1 WAKE TURBULENCE 1 FUEL EXHAUSTION 1 HARD LANDING (180 accu. lnd.) 1 GEAR-UP 3 LANDING (loss of control) 214

17. FY 2008 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFISOLO 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) 219

18. FY 2009 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFISOLO 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) 25

19. FY 2010 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFISOLO 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) 615

20. FY 2011 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFISOLO 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) 320

21. FY 2012 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFISOLO 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) 04

22. Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Student & CFI hard landings, gear-ups, & loss of control YearTotal EventsLanding EventsRatio 2007 30 20 67 % 2008 44 30 68 % 2009 24 16 67 % 2010 32 25 78 % 2011 33 27 82 % 2012 17 9 52 %

23. FY 2013 ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCE STUDENT & CFISOLO STUDENT GEAR-UP 1 HARD LANDING 1* * during practical test LANDING (loss of control) 02

24. Other Major Contributors to Orl FSDO Flight Training Accidents & Incidents Student & CFI hard landings, gear-ups, & loss of control YearTotal EventsLanding EventsRatio 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 %

25. 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.

26. Opportunities for Improvement Group Discussion Recommendations MorePINK

27. Opportunities for Improvement More Notices of Disapproval

28. Orlando FSDO Flight Training Accidents & Incidents Involving Landings Student & CFI hard landings, gear-ups, & loss of control YearTotal EventsLanding EventsRatio 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 %

29. 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

30. Opportunities for Improvement Think PINK

31. Additional Contributors to Orl FSDO Flight Training Accidents & Incidents Other Aircraft Flight Training & Testing Gliders Helicopters

32. Additional Contributors to Orl FSDO Flight Training Accidents & Incidents Helicopter Hard Landing, Hover, and Autorotation Events YearTotal EventsHelo EventsRatio 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 %

33. 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.

34. Additional Helicopter Information Helicopter Examiner NVG Authorization New Helicopter Flying Handbook Steve Weaver

35. AIRWORTHINESS INITIATIVE The Orlando FSDO continues to place special emphasis on the airworthiness compliance of flight training aircraft. Inspections Analysis of Data

36. FY 2012 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCECAUSE 1 SR-20 emer. landing on road Engine failure 1 CE-172 emer. landing in field Engine failure 1 HU-269 emer. autorotation into field Engine failure 1 CE-172 smoke in cockpit Voltage 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 flight Latch design 4 PA-28 engine fires while starting Carb. flooding 1 SR-20 brake failure Overheated brakes 1 PA-28 propeller blade broke off Undetermined

37. FY 2013 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY OCCURRENCECAUSE 1 Loss of control during taxi while turning Loss of brake pressure

38. AIRWORTHINESS INITIATIVE New initiativeto improve AirworthinessCompliance of Pilot Schools operating Flight Training Aircraft Airworthiness Designee Focal Point Joe Gramzinski DPE Airworthiness Liaison Pete Kandravi