FINAL INVESTIGATION REPORT ON INCIDENT TO M/s GUJARAT

FLYING CLUB, CESSNA FA 152 AIRCRAFT, VT-EMM, ON 19.03.2020 AT

VADODARA

GOVT OF INDIA
O/O DIRECTOR AIR SAFETY
WESTERN REGION
NEW INTEGRATED OPERATIONAL COMPLEX
SAHAR ROAD
VILLE PARLE (EAST)
MUMBAI-400099
 INDEX
Section Subject Page No.
General Information 1
Synopsis 2
1.0 Information 2
1.1 History of Flight 2
1.2 Injuries to Persons 4
1.3 Damage to Aircraft. 4
1.4 Other Damage 5
1.5 Personnel Information 6
1.5.1 Pilot in Command/ Trainee Pilot 6
1.6 Aircraft Information 7
1.7 Meteorological Information 8
1.8 Aids to Navigation 8
1.9 Communications 9
1.10 Aerodrome Information 9
1.11 Flight Recorders 9
1.12 Wreckage & Impact Information 9
1.13 Medical and Pathological Information 11
1.14 Fire 11
1.15 Survival Aspects 11
1.16 Tests and Research 11
1.17 Organizational and Management Information 13
1.18 Additional Information 13
1.19 Useful or Effective Investigation Techniques 16
2.0 Analysis 16
2.1 Serviceability of Aircraft & Maintenance Aspects 16
2.2 Pilot handling of the Aircraft 17
2.3 Weather 18
2.4 Training Aspects 18

3.0 Conclusion 19
3.1 Findings 19
3.2 Probable Cause 20
3.3 Contributory Factors 19 20
4.0 Safety Recommendations 20

Abbreviations 21
 In accordance with Annex 13 to the ICAO Convention on International
Civil Aviation and Aircraft (Investigation of Accidents and Incidents) Rules,
2017 of India, the sole objective of this investigation is the prevention of
aircraft incidents & accidents. It is not the purpose of this activity to
apportion blame or liability.
 FINAL INVESTIGATION REPORT ON INCIDENT TO M/S GUJARAT
FLYING CLUB, CESSNA FA 152 AIRCRAFT, VT-EMM, ON 19.03.2020
AT VADODARA
GENERAL INFORMATION:

a) Aircraft Type & Model : Cessna FA 152 Aircraft

Nationality: Indian
Registration : VT-EMM
b) Owner : M/s The Aero Club of India
c) Operator : M/s The Gujarat Flying Club
d) Pilot in command : SPL holder
e) Extent to injuries : Nil
f) First Officer : N/A
g) Extent to injuries : N/A
h) Passengers onboard : Nil
i) Extent to injuries : N/A
j) Place of incident : Vadodara, Gujarat (VABO)
k) Co-ordinates of Incident site : N 22.340563, E 73.230490
l) Date and time of Event : 19.03.2020, Approx. 11:33 IST
m) Last Point of Departure : VABO
n) Point of Intended Landing : VABO
o) Type of operation : Training flight (Solo)
p) Phase of operation : Landing
q) Type of Incident : Abnormal Runway Contact

(All timings in the report are in IST, unless otherwise specified)

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SYNOPSIS:

On 19.03.2020, M/s The Gujarat Flying Club, Cessna FA 152 Aircraft,

VT-EMM was involved in nose landing gear collapsed incident while landing
at Vadodara airport, Gujarat. The aircraft was engaged in a solo circuit and
landing exercise at Vadodara airport by a trainee pilot. The incident flight
was the first solo flight of the trainee pilot. During landing, the aircraft
touched on nose landing gear and bounced resulting in damage to the nose
landing gear and propeller blades. There was no injury to the trainee pilot.
There was fuel leakage, however there was no fire.

DGCA ordered the investigation of the incident by appointing an

Investigator-in charge under Rule 13(1) of the Aircraft (Investigation of
Accidents and Incidents) Rules, 2017.

The investigation has revealed that the incident occurred due to

improper flare techniques during landing resulted the aircraft to touch the
runway on Nose wheel and bounce. Subsequent improper bounce recovery
techniques caused multiple bounce and damage to Nose landing gear and
engine propeller. The loose tube axle inside the bearing led to the detaching
of the nose gear wheel on impact

Inadequate training on Go-Around Procedure, Recovery from Bounce,

Balloon & PIO/Runway change procedure to trainee pilot prior to solo release
flight are the contributory factors to the incident.

1.0 FACTUAL INFORMATION

1.1 HISTORY OF THE FLIGHT

On 19th March 2020, Cessna FA 152 aircraft, VT-EMM of M/s The

Gujarat Flying club was involved in an incident of abnormal runway contact
during landing at Vadodara, Gujarat. The aircraft was under command of
trainee pilot. The incident flight was authorised by CFI for Trainee pilot to
carry out her first solo circuit and landing exercise. Prior to incident flight,
05 circuit & landings were conducted for the Trainee Pilot by CFI on Aircraft
VT-EMM on the same day. During the previous sortie (5th circuit and
landing), CFI requested to ATC to have one more circuit and landing for the
same trainee pilot. ATC informed only one circuit and landing is possible due
arrival of one of Commercial flight (Flight No. IGO2026). CFI confirmed and
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informed to ATC that trainee pilot will be carrying out solo flight. Aircraft
parked at stand 5 and CFI came out. Trainee pilot was released for her first
solo flight. Trainee pilot taxied the aircraft VT-EMM and took off at around
11:23 Hrs IST and carried out Left hand circuit on RWY22. The flight was
uneventful till the final approach. The approach was stabilised, and the
winds were calm.

As per statement of trainee, the airspeed was approx. 65 kts while

landing & the flap configurations was 20 degrees. At around 11:30 Hrs IST
during landing the aircraft was flared out at high, while controlling the
landing Trainee pilot pushed the control column a bit more forward than
needed. Subsequently the nose wheel touched down first, aircraft bounced
and then the main landing gears touched, and trainee pulled the control
column again and the aircraft bounced three times. During bounce landing
the propeller hit the runway surfaces twice and both propeller blades were
bent. The nose wheel was detached due impact & the nose landing gear
collapsed, aircraft veered off to the Right edge of RWY22 and stopped. The
aircraft was finally rested on basic strip outside the RH Side Runway edge of
RWY 22 at distance approx. 27.5 Meters from the Runway centreline and
approx. 582 Meters from RWY 22 threshold.

The aircraft was in a Tail high position and trainee pilot was stuck in
her seat. No distress call was made by the trainee pilot. Fuel was spilled from
the aircraft and there was no fire. Fire station was advised on WALKIE-
TALKIE to proceed towards the crash site, information regarding Passengers
on-board and grid location was passed to fire station. Crash siren and crash
bell were pressed simultaneously. Trainee pilot was reported safe by Fire
personnel. Commercial Flight IGO2026 was advised to hold overhead
Vadodara due to runway blockage. Rescue team came and trainee pilot was
carried by ambulance to the Airport’s MI Room and clinically examination
conducted. No injury was reported.

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 1.2 INJURIES TO PERSONS:

Injuries Crew Passengers Others

Fatal 00 00 00
Serious 00 00 00
Minor/ None 01 00

1.3 DAMAGES TO THE AIRCRAFT:

Post Incident, Cessna FA 152 aircraft, VT-EMM had received the following
damages:

1. Due impact the nose landing gear fork found broken, subsequent the
nose landing gear wheel detached from Nose landing gear fork & Nose
wheel assembly also damaged. (Fig 01)

Fig 01 Photograph shows Nose landing gear fork & Nose landing
gear assembly damaged

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 2. Due Propeller hit to the runway surfaces, both propeller blades were
bent

Fig 02 Photographs shows Propeller blades bent

1.4 OTHER DAMAGE: One Runway Edge lights (# B-124) of RH side of

RWY 22 was found broken by Aircraft VT-EMM.

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1.5 PERSONNEL INFORMATION
1.5.1 PILOT IN COMMAND (TRAINEE PILOT):

AGE 19 Years, Female

License SPL (student pilot
license) Holder
Date of License Issue and Valid up to Issued date: 17.10.2016,
Validity:16.10.2021
Category Aeroplane
Date of Medical (Class-II) Exam & validity Exam date: 10.07.2018
Validity: 09.07.2020
Date of FRTOL issue & validity Issued Date: 18.12.2017
Validity: 17.12.2027
IR rating and instructor rating N/A
Total Flying Experience 28:50 Hrs
Total flying experience during last 1 year 15:30 Hrs
Total flying experience during last 06 06:55 Hrs
months
Total flying experience during last 30 days 04:45 Hrs
Total flying experience during last 07days 01:35 Hrs
Total flying experience during last 24 Hrs 00:50 Hrs

Duty time last 24 Hrs Nil

Rest before the flight More than 24 Hrs

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On 19.03.2020, the trainee had carried out 05 circuit and landings at
Vadodara airport on RWY22 along with CFI before the incident flight and
trainee pilot was debriefed.
As per progress report, Student was briefed for the standard circuit pattern
and procedures, approach, and landing, checks as per checklist, given
practise for the same. Student found to perform consistent in circuit,
approach and landing corrections, lookout scan of flight parameters was all
satisfactory.
Final approach and landing were found to be safe and satisfactory. Found fit
to fly solo and released for First Solo.
The flight time and flight duty times were within the limits. No
incident/accident involvement of Student pilot was observed from the
previous records.
From the Flight Trainee’s progress report, the irregular flying with lots of
break period is observed which might have affected her learning &
performance. The trainee has joined the flying club in year 2016 and her first
training flight was on 17.10.2016. Trainee Pilot has flying experience of 21:55
Hrs with longer interval between flying, however from 30.01.2020 onwards,
trainee was regular at the flying club, and trainee flew training sorties on
circuit & landing exercise with other instructors at the flying club and
completed only 28:50 Hrs since joining.

1.6 AIRCRAFT INFORMATION:

The details provided below are as on prior to incident flight.
Aircraft Registration VT-EMM
Type of Aircraft Cessna FA 152
Aircraft Serial No. FA-152-0392
State of Manufacturing France
Manufacturing year 1986
Owner M/s Aero Club of India, New Delhi
Operator M/s The Gujarat flying club, Vadodara
Certificate of 1812 dated 11/09/1986
Airworthiness number
and issue date
ARC number and Validity EMM/1812/ARC/6TH/2019221 Valid up to
29/12/2020
Aircraft TSN TSN :23520:05 Hrs
Maximum All Up Weight 760 Kg
Minimum crew necessary One
Engine Type, Sl.No., TSN, Type : LYCO 0-235-N2C, S/N: L-24122-15,
TSO TSN: 15643:35 Hrs, TSO: 2027:25 Hrs

Propeller Type & Sl no. Type: Mccualley 1A103, Sl No. :NF-012

Last weight scheduled 01-08-2013
carried out date

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 Aero Mobile station A-151/WRLO-19 valid up to 31.12.2022
licence and validity
Any Major/Scheduled 100 Hrs/12 months inspection carried out on
inspection prior to the 26.02.2020 at 23435:50 A/F hours & 50 hrs
incident inspection carried out on 08.03.2020 at 23475:50
A/F hours which also includes the inspection of
NLG for condition and security of attachment

After completion of Daily Inspection schedule and Pre-departure schedule

aircraft was released to service on 19/03/2020 for the routine training sortie.
As per the Load & Trim sheet, the Centre of Gravity was within limits. No snag
was reported to Aircraft before the incident flight.

1.7 METEOROLOGICAL INFORMATION:

Meteorological report was available with the crew for briefing before flight. The
Aircraft VT-EMM took off at 1120 Hrs & after completion of circuit Aircraft
landed at Vadodara Airport at approx. 1130 Hrs IST. The METAR obtained
from Vadodara airport on the date of incident from 11:00 IST (19.03.2020)
Hrs to 11:30 IST (19.03.2020) Hrs are quoted as below:

Report time
in IST 11:00 11:30 12:00
Winds Calm Wind from 180° Calm
at 04 knots

Visibility 5000m 5000m 5000m,

Temperature30°C 31°C 32°C

Dew point 16°C 17°C 16°C
QNH 1012 hPa 1012 hPa 1012 hPa
Weather NOSIG NOSIG NOSIG

1.8 AIDS TO NAVIGATION:

Vadodara airfield is a licenced Civil-Defence airfield, and the operations are

controlled by the Airports Authority of India. There is single runway available
at Vadodara airfield which has the orientation 04/22. SAPL Available for
Runway 04/22 However the ILS landing facility is available for runway 22
only. The PAPI is available for the runway 04 / 22. Aerodrome Beacon is
available at the Aerodrome. Two-way VHF communications is available at the
airport. There were no known navigation aid difficulties reported by the
Trainee pilot.

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1.9 COMMUNICATION:

Aircraft is equipped with Very High Frequency sets and a High Frequency set
for communication. There was always two-way communication established
between the ATC and aircraft. However, post incident Trainee pilot could not
make a distress call on VHF.

1.10. AERODROME INFORMATION:

Vadodara (VABO) airfield is a licensed Civil-Defence airfield, and the

operations are controlled by the Airports Authority of India. There is single
runway available at Vadodara airfield which has the orientation 04/22 having
length 2589 Meters and width 150 Meters. The Runway Surface is made of
Bitumen. Both Runway directions are in use depending upon the wind
direction. SAPL Available for Runway 04/22 However the ILS landing facility
is available for runway 22 only. The PAPI is available for the runway 04 / 22.
Aerodrome Beacon is available at the Aerodrome. Two-way VHF
communications is available at the airport. The ATC is controlled and manned
by M/s Airports Authority of India (AAI).
The emergency services i.e., the fire fighting vehicle and the medical facilities
is manned by the M/s AAI. The elevation of Vadodara Airfield is 121 feet. As
per ATC, Post-incident site inspection & runway inspection were carried out,
there were no abnormalities observed on Runway 22 or in the vicinity of the
Incident Site.

1.11 FLIGHT RECORDERS: Aircraft is neither fitted with any flight

recorders nor required on this aircraft as per Civil Aviation Requirements.

1.12 WRECKAGE & IMPACT INFORMATION:

The aircraft was found disabled outside the RH Runway Edge of RWY 22 on
basic strip at distance approx. 05 meters from the Runway Edge and
approx. 582 Meters from RWY 22 threshold. & Nose Landing gear wheel
was detached due impact on Nose landing gear during landing on
touchdown. (Shown in Fig 03)
Nose Landing gear wheel was found from a distance 12.4 meters from the
LH Runway Edge and approx. 464 Meters from RWY 22 threshold. (Shown
in Fig 04). Fuel leak from the aircraft was observed. There was no fire on
the aircraft after Aircraft veered off from RWY 22 to the RH Runway Edge.

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Following External Damages observed to Aircraft VT-EMM during visual
inspection of the aircraft:

a) Nose landing gear found broken with its mount on firewall.

b) Nose landing gear fork found broken.
c) Nose wheel assembly found damaged.
d) Nose wheel found detached on LH side of RWY22.
e) Nose gear steering linkages (LH found broken and RH found bent)
f) Dent found in lower part of firewall.
g) Fuel strainer fuel line found bent.
h) Fuel Strainer mounting found bent.
i) Engine tubular mount found broken.
j) Propeller found bent on both edges.
k) Damage to Engine internal parts suspected due to propeller strike.
l) Engine lower cowl found damaged.
m) Exhaust tail pipe found damaged.
n) Cabin heat linkage found broken.
o) Dent found on Horizontal Stabilizer (RH) with crack on leading edges.
p) RH main landing tube found bent & damaged.
q) Bolt (Connecting NLG Fork, Tube Axle and Ferrule) was not recovered
from the incident site.

Fig 03. Aircraft VT-EMM in tail high position on right side runway edges
of RWY22

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Fig 04. Runway diagram depicts the flight profile VT-EMM after
touchdown to final rest position

1.13 MEDICAL AND PATHOLOGICAL INFORMATION:

Post-Incident, the involved trainee pilot was undergone Breath Analyzer

test for Alcohol at Vadodara airport and result was found to be negative.

1.14 FIRE: There was no fire. However, there was a fuel spillage after
incident.

1.15 SURVIVAL ASPECTS: Incident was survivable.

1.16 TESTS & RESEARCH:

The failed / damaged parts of the nose wheel assembly were examined in
Aircraft Engineering Directorate, DGCA Hqrs. Upon examination, The
Inner Diameter of bearing inner race and Outer Diameter of tube axle at
the corresponding bearing locations have been dimensionally examined
and it is found that the parts under excessive clearance /play (undersized)
in their assembly from the prescribed limits observed. Hence, tube axle
(As Shown in Fig.05) is worn out and undersized at the bearing diameter
locations. There was an indication of undersized tube axle, circumferential
rubbing marking and pitting were noticed on the tube axle.

The worn-out tube axle outer diameter at the bearing locations would have
eased the bearing units to rotate over the tube axle. This could have also
caused the entire wheel assembly along with bearing unit (which is
restrained by ring retainer within the wheel assembly) to move on lateral
direction. The lateral movement of the wheel would have probably caused
offsetting of wheel loading on the tube axle, movement of bearing units
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close to ferrule’s inner surfaces & causing subsequent rubbing, also
causing slipping of one ferrule unit by approximately 90 degree and
enlargement of bolt holed on the ferrule perhaps due to load offset.

Over a period, the stated events would have loosened the fastening of NLG
tube axle unit with NLG Fork and perhaps caused the disintegration of wheel
unit from NLG due overload and exposing the fork to come in direct contact
with landing surface. The chip off/ flaking away of rolling elements within
the rollers also suggestive of overload due to offset wheel loading. Other
failures like, steering tube, steering tube linkage failure, shimmy damper
lug failure and wheel rim damage are consequential failures.

Wheel assembly detachment failure could have probably due impact

contributed by undersize/ worn out tube axle and subsequent the NLG
collapsed.

The nose landing gear assembly is to be inspected during 100 Hrs/12

months & 50 hrs inspection which includes the inspection of NLG for
condition and security of attachment, however there is no specific inspection
to measure the dimensions of axle tube and the bearing of the nose wheel.

TUBE AXLE

Fig.05 Cessna FA 152 Aircraft Nose landing Gear Assembly

The Engine of the involved Aircraft was also sent for strip investigation at
the approved vendor’s Facility. There is no major damage to the internal
parts of the Engine observed. The external damages observed on parts and

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 accessories were due to the impact of the engine at the time of incident.
The carbon deposits noticed on piston dome is a normal as observed on
engine received. As per the Strip investigation report, the engine was
running and delivering power at the time of incident.

1.17 ORGANIZATIONAL & MANAGEMENT INFORMATION:

M/s Gujarat flying Club is a flying training organisation (FTO) located at

the AAI Airport, Vadodara. The Approval of the FTO was done on 07 April
2016 and is valid till 06 April 2021. The FTO has one CFI, one Dy.CFI,
two FI and 04 API for imparting training to the trainee pilots. The FTO has
a total of three Aircraft, One Cessna 172 and two Cessna 152s. The FTO
has in house maintenance set up under CAR M Sub part F & G which is
valid till 31 December, 2020.

1.18 ADDITIONAL INFORMATION:

1.18.1
There was a similar incident occurred to M/s Falcon Aviation Academy,
Cessna 152 Aircraft, VT-PTB at Faizabad on 04.03.2015. In this case,
during landing at flare, the trainee pilot felt a sudden sink in the aircraft.
The aircraft bounced on the main landing gear. The trainee pilot tried to
control the aircraft by pulling the nose but she could not control the aircraft
and the aircraft again sank and bounced on the main landing gear for the
second time. It finally landed on the nose gear during the third impact.
There were no injuries to the trainee pilot. Due to the impact, the nose gear
sheared off from the fork attachment fitting the similar issue of tube axle
found loose (running) with the bearings of the nose landing gear wheel was
observed.

Probable Cause of the incident was Student pilot improper flare during
landing made the aircraft bounce and her improper bounce recovery
technique to recover from the bounced landing resulted into the incident.
The loose tube axle inside the bearing led to the breaking of the nose gear
on impact.

During the investigation of the failed nose wheel at DGCA HQ, indication of
poor maintenance in the nose wheel area was observed. The tube axle was
found to be undersized beyond manufacturer specified limits. The loose
tube axle inside the bearing led to the breaking of the nose gear on impact.

Based on findings one of Safety recommendation was to carry out onetime

inspection to measure the dimensions of axle tube and of the bearing of the
nose wheel of the entire fleet of the flying club.

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 1.18.2ATC tape recording was available and used for the facts and
analysis. Events based on ATC tape transcript are as follows:
05:44:12 From the ATC tape transcript, VT-EMM (CFI) has requested one
more circuit landing for the trainee pilot as Solo. ATC replied only one circuit
is possible due arrival.
05:44:12, VT-EMM requested for taxi instruction from stand 5
05:46:23 VT-EMM was cleared to taxi to holding point of RWY22
05:47:22 VT-EMM was cleared to follow Left hand circuit after departure.
05:47:58, VT-EMM was requested to confirm to expedite the departure due
arrival of Indigo2022, VT-EMM replied affirmative
05:48:10 VT-EMM was cleared to line up on RWY22 and report ready for
departure and to expedite
05:50:06 VT-EMM was requested present position for line up
05:50:30,VT-EMM again requested for present position for line up
05:50:36, VT-EMM replied negative and inform will call you when ready for
departure
05:52:06, VT-EMM reported ready for departure At 05:52:09, Tower
reported whether and winds were copied by VT-EMM and cleared for take-
off In mean time, IAF aircraft was also ready for departure and was at
holding point F cleared for departure after the circuit landing flight of
aircraft VT-EMM, and arrival of Indigo flight 2026 on RWY 22.
05:54:08 VT-EMM was requested to report on final, VT-EMM was airborne
at 05:54:08 VT-EMM was requested to report on final,
05:55:04 VT-EMM reported on left downwind RWY 22
05:57:46 VT-EMM reported on final
05:57:50 Tower reported wind calm RWY22 clear to land
05:57:56 VT-EMM reported clear to land and winds copied
05:58:53 IGO2026 was requested to report on 30 miles
06:00:00 tower reported IGO 2026 to hold overhead due RWY delay not
determined as the Cessna skid off RWY22
06:01:00 IAF aircraft was requested to proceed back due Cessna 152 skid off
06:04:48 IGO 2026 was requested to stop descent at FL55
06:04:50 IGO 2026 was advised that delay not determined as of now.
06:06:24 IAF aircraft went back to dispersal with the Marshaller
Further the Aircraft VT-EMM was removed from the basic strip after clearance from
Office of Director Air Safety (WR), Mumbai and the IGO 2026 was landed.
(All timings are mentioned in ATC tape transcript are in UTC):
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 1.18.3 FIRST SOLO RELEASE PROCEDURE & REQUIREMENTS:
As per TPM of M/s GFC Chap 5 para 15 “before the first solo flight”,
Quote “FIRST SOLO for this exercise the instructor should make it clear to
the student that he is to make only one circuit and landing unless he needs
to overshoot. The student should also be told that if on landing he makes a
large bounce or for some reason the landing does not seems to be turning
out well, he should not be ashamed of going around again. After a bounced
landing, the balked landing procedures, where go-around should be
executed” Unquote.

1.18.4 TRAINEE PILOT’S SUBMISSION

Aircraft VT-EMM was parked at stand 5, CFI got out from the aircraft and
then trainee pilot asked for taxi instructions and got cleared for left hand
circuit to RWY22. The circuit carried out was proper and gave a downwind
call on the RT and the finals call on RT when turned on finals, called out
that the approach was stabilised, got my power back to 1500 rpm on finals,
because the winds were calm. Then when the runway edges were opening,
she called out that the runway edges are opening and got the throttle to idle
at the threshold. After that she flared out a bit high, while controlling the
landing she pushed the control column a bit more than needed.
Subsequently the nose wheel touched down first, bounced and then the
main landing gears touched and pulled the control column and the aircraft
bounced again and again, bounced three times. After that the aircraft
veered to the right edge of the RWY22 and stopped because she had pressed
the brakes. Later she tried to transmit on RT, but it stopped working, she
tried to open her seat belt as well, but the aircraft was in a tail high position
and was stuck in seat. Later the rescue team came and opened seat belt
and carried her to MI room by ambulance. On clarification, following were
added to her statement:
 The speed was high on approach and incident flight was her first solo
flight.
 The CFI had briefed on the balloon & bounce recovery techniques except
the go around procedures.
 The Airspeed was approximately 65 knots while landing and flap
configuration was 20 degrees.

1.18.5 CHIEF FLIGHT INSTRUCTOR’S SUBMISSION

Trainee has total flying of 28:50 Hrs and has been given sufficient dual
training on normal circuit and landing exercises. During day sortie, Trainee
was briefed for normal circuit and approach to land exercises. Trainee
carried out checks and procedures, taxied and carried out circuits and
landings satisfactorily.
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On 19.03.2020, before her release for first solo check sortie, 05 standard
circuit & landing exercise were carried out. Out of five, first circuit was
carried out CFI with trainee assisted on flight controls as a demonstration
expected for the correct circuit pattern and approach and landing expected
by the trainee in the check. Onwards four circuits were flown by the trainee
herself and her performance during the check was found to be consistent
for correct approaches and safe landing with corrective actions as required.
Hence overall assessment for the trainee to carry out ONE SOLO Circuit
after this check found to be steady, consistent & safe enough. After consent
from trainee & upon ATCO’s clearance, the trainee was released for her first
solo-one circuit to land.
Prior to releasing her solo and during dual check, trainee was given
demonstration of corrective actions for high balloon/bounce.
Performance of trainee for the entire sortie found to be safe and satisfactory.
Winds were calm and trainee was released for her first solo.
During her solo flying, From ATC tower CFI supervised her circuit pattern
and final approach and landing maneuvers. It was observed that the take-
off, climb after take-off, circuit pattern and final approach carried out by
trainee as solo occupant was normal as expected. However, landing
maneuver and corrective action taken by the trainee found to be not correct
as briefed/ demonstrated during the dual training sorties. It was observed
that the Aircraft bounced and ballooned, and the trainee pilot gave
unexpected/ wrong corrective inputs, i.e., pushing the control column
forward which have been warned/ instructed to trainee many times during
her training sorties. As a result of which the aircraft nose wheel collapsed
with propeller hit on the runway surface and aircraft stopped with runway
excursion.

1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES: NIL

2.0 ANALYSIS:

2.1 SERVICEABILITY OF THE AIRCRAFT & MAINTENANCE ASPECTS:

After completion of Daily Inspection schedule and Pre-departure schedule

the aircraft VT-EMM was released with valid C of A and ARC, Nil snags
and no active MEL invoked before the incident flight. Aircraft was
airworthy before the incident flight.
During the investigation of the failed nose wheel at AED, DGCA HQ,
indication of poor maintenance in the nose wheel area was observed. The
tube axle was found to be undersized beyond manufacturer specified
limits. The loose tube axle inside the bearing led to the detachment of the
nose gear wheel from NLG forks on impact and subsequent the NLG
collapsed. The scheduled 100 Hrs. /12 months inspection carried out on
26.02.2020 at 23435:50 A/F hours & 50 hrs. Inspection carried out on
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 08.03.2020 at 23475:50 A/F hours which also includes the inspection of
NLG for condition and security of attachment. However, there is no
specific task/inspection to measure the dimensions of axle tube and of
the bearing of the nose wheel.
As per the Strip investigation report of the Engine, the engine was running
and delivering power at the time of incident.
Trainee pilot informed that she could not make distress call on R/T.
However, when Maintenance Manager reached to incident spot and
opened the door to put the master switch off for preventing the fire hazard,
he listened the R/T call before switching off the master switch.
In absence of specific maintenance task/inspection to measure the
dimensions of NLG axle tube and diameter of inner race of the bearing of
the nose wheel, the looseness between them could not be inspected which
might have led to the detaching of the nose gear wheel on impact. As these
are not covered any maintenance schedule, the maintenance aspects of
the Aircraft may not be considered a contributory factor to the incident.

2.2 PILOT HANDLING OF THE AIRCRAFT:

Prior to the incident the trainee pilot underwent 05 circuits & landing
exercise. Based on the satisfactory performance of trainee, CFI requested
ATC if they could get one more circuit for trainee pilot to go solo. The ATC
informed only one circuit is possible, and CFI informed that the trainee
would carry out only one circuit and landing. This was the first solo flight
for the trainee pilot.

Aircraft took off at around 11:23 Hrs IST and carried out Left hand circuit
on RWY22. The flight was uneventful till the final approach. It was
observed that the take-off, climb after take-off, circuit pattern and final
approach carried out by trainee as solo occupant was normal. The
approach was stabilised, and the winds were calm. As per statement of
trainee, the airspeed was approx. 65 kts while landing & the flap
configurations was 20 degrees.
The Aircraft was flared out at high, while controlling the landing Trainee
pushed the control column a bit more forward than needed. Subsequently
the nose wheel touched down first, bounced and then the main landing
gears touched, and trainee pulled the control column and the aircraft
bounced three times after that the aircraft veered to the right edge of the
RWY22 and stopped as applied brakes. Later Trainee pilot could not
transmit/ make a distress call on R/T and tried to open seat belt, but the
aircraft was in a tail high position and trainee pilot was stuck in seat.
Later the rescue team came and opened seat belt and rescued her.
The trainee pilot was inside the cockpit till the rescue team reached to
incident site which could have been dangerous as there was a fuel spillage
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which could have resulted into post impact fire. The pilot handling is
considered as a factor to the incident.
Post incident, the trainee pilot did not put the mixture ignition switch and
master switch to OFF position. The Maintenance manager of M/s Gujarat
flying club when he reached to incident spot, he opened the door and put
the master switch to OFF position for preventing the fire hazard.
Hence, it can be concluded that the pilot handing of the aircraft is the
main factor to the incident

2.3 WEATHER:

From the available metrological information and statement of the

involved trainee pilot, the wind was calm at the time of incident.
Hence, it can be concluded that Weather was not a contributory factor to
the incident.

2.4 TRAINING ASPECTS:

The trainee Pilot has joined the flying club in year 2016. Her first training
flight was on 17.10.2016 and till 19.09.2019 She has flying experience of
21:55 Hrs with longer interval between flying, however from 30.01.2020
onwards, trainee was regular at the flying club, and trainee flew training
sorties on circuit & landing exercise with other instructors at the flying
club and most of the time the approach & landing were assisted by Flying
instructor and debriefed as needs to be consistent and proactive, however
the overall performance of the trainee was found to be satisfactory.
From the Flight Trainee’s progress report, the irregular flying with lots of
break intervals are observed which might affected her learning &
performance.
On 19.03.2020, before her release for first solo check sortie, 05 standard
circuit & landing exercise were carried out. Out of five, first circuit was
carried out CFI with trainee assisted on flight controls as a demonstration
expected for the correct circuit pattern and approach and landing
expected by the trainee in the check. Onwards four circuits were flown by
the trainee herself and her performance during the check was found to be
consistent for correct approaches and safe landing with corrective actions
as required. Hence overall assessment for the trainee to carry out ONE
SOLO Circuit after this check found to be steady, consistent & safe
enough. After consent from trainee & upon ATCO’s clearance, the trainee
was released for her first solo flight, i.e. one circuit to land. However, as
per submission of Trainee pilot, three circuit & landing were assisted by
CFI and last two Circuit & landing exercise were carried out by the trainee
pilot.
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 As per Statement of Trainee Pilot, on 19.03.2020, prior to releasing her solo
and during dual check, CFI had briefed the trainee pilot on the balloon &
bounce recovery technique except the go around procedures. However, From
the Flight Trainee’s progress report, the trainee was not briefed for Go-
Around Procedure, Recovery from Bounce and Balloon & PIO/Runway
change procedure for prior her first solo exercise.

From the statement of trainee, Chief flight instructor & Flight trainee’s
progress report, it can be concluded that the inadequate trainings for Go-
Around Procedure, Recovery from Bounce, Balloon & PIO/Runway change
procedure for prior to solo release flight is a contributory factor to the
incident.

3.0 CONCLUSION:

3.1 FINDINGS:

3.1.1 The Aircraft had valid C of A and ARC before the incident flight
and there was no snag reported to the aircraft before and during
the flight.
3.1.2 Post incident the Trainee pilot had undergone the BA test for
alcohol and the result was negative.
3.1.3 The incident flight was trainee pilot’s first solo flight.
3.1.4 From the Flying trainee’s progress record, the longer intervals of
non-flying are observed from period from 17.10.2016 to
19.03.2020 and completed only 28:50 hrs since joining.
3.1.5 From the Flight Trainee’s progress report & Trainee Pilot’s
statement, the trainee was found to be not briefed/ trained for Go-
Around Procedure, Recovery from Bounce, Balloon & PIO/Runway
change procedure for prior to her first solo exercise.
3.1.6 Improper flare techniques by trainee pilot during landing resulted
the aircraft to touch the runway on Nose wheel and bounce.
Subsequent improper bounce recovery techniques causes multiple
bounce and damage to the nose landing gear and engine propeller.
3.1.7 Post incident, the trainee pilot did not put the mixture ignition
switch and master switch to OFF position. Trainee pilot could not
transmit/ make a distress call on R/T.
3.1.8 The trainee pilot could not come out from the Aircraft till the rescue
team reached to incident site.
3.1.9 The loose tube axle inside the bearing led to the detaching of the
nose gear wheel on impact.
3.1.10 There is no any specific maintenance task/inspection to measure
the dimensions of axle tube and of the bearing of the nose wheel
for Cessna 152 type Aircraft.
3.1.11 Probably Weather was not a contributory factor.
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 3.2 PROBABLE CAUSES:

Improper flare and bounce recovery techniques during landing resulted in

multiple bounces and damaged to the nose landing gear and engine propeller.

3.3 CONTRIBUTORY FACTORS:

Inadequate trainings on Go-Around Procedure, Recovery from Bounce,

Balloon & PIO/Runway change procedure prior to solo release flight was a
contributory factor to the incident.

4.0 SAFETY RECOMMENDATIONS:

4.1 Suitable Corrective training to trainee pilot.
4.2 Action deemed fit by DGCA HQ based on findings made in the
report.

Digitally signed by
DILIP BABUBHAI
CHAVDA
Date: 28.06.2021 Dilip Chavda
Place: Mumbai Air Safety Officer &
Investigator-in-charge, VT-EMM

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 Abbreviations
# Number
AAI Airports Authority of India
AED Aircraft Engineering Directorate
A/F Airframe
ARC Airworthiness review certificate
AMM Aircraft maintenance manual
API Assistant Pilot instructor
ATC Air traffic control
ATCO Air Traffic controller
BA Breath Analyzer
C/L Checklist
C of A Certificate of Airworthiness
CPL Commercial pilot licence
CFI Chief Flight Instructor
CAR Civil aviation requirements
DGCA Directorate General of Civil Aviation
Dy CFI Deputy Chief Flight Instructor
FRTOL Flight Radio telephone operator’s licence
FTO Flying Training Organization
FTPR Flight trainee’ Progress report
GFC The Gujarat Flying Club
FI Flight Instructor
ft. Feet
HQ or Hqrs Head Quarter
Hrs Hours
ILS Instrument landing system
ICAO International Civil Aviation organization
Kg Kilogram
LDA Landing distance available
LH Left Hand
LHS Left hand side
MEL Minimum equipment list
METAR Meteorological terminal aviation routine weather report OR
Meteorological aerodrome report
M/s Messers
MSL Mean Seal Level
NA or N/A Not Applicable
NLG Nose Landing Gear
NG Next Generation
PAPI Precision approach path indicator
PIO Pilot induced Oscillation
QNH Query Nautical Height
P/N Part Number
RH Right hand
RHS Right hand side
RC Route check
RTR Radio telephony restricted (Aeronautical)
R/T Radio telephony
RVR Runway visual range
RWY or R/W Runway
SPL Student pilot licence
SAPL Simple Approach lighting
Sl No. Serial Number
THR Threshold
TBO Time between overhaul
TPM Training and Procedures Manual
TSN Time since new
TSN Time Since Overhaul
TODA Take-off distance available
TORA Take-off run available
UTC Universal time coordinated
VABO Vadodara Airport (ICAO)
VHF Very high frequency
VOR VHF Omni range

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