Aircraft Accident Investigation Report

51 2.0 ANALYSIS 2.1 Pilot Decision Making The pilot’s decision to continue the take-off phase of the flight after experiencing a partial loss of engine power shortly after liftoff along with the decision to turn the aircraft rather than the accepted practice of maintaining a flight path straight ahead adversely affected the outcome of the flight resulting in a stall caused by failure to maintain airspeed. This accident demonstrates the need for guidance to be developed in the area of pilot decision making for general aviation pilots. The circumstances of this accident could be instructive to other general aviation pilots in raising their awareness of potential decision making errors 2.2 Aircraft Performance From the information provided, the aircraft was below the maximum weight and the center of gravity was within the limits as set out in the aircraft type certificate data sheet. The statements provided by witnesses indicated that the aircraft’s rate of climb and speed were slow and that shortly after the aircraft made a left turn, it rapidly rolled off on a wing and descended steeply to the ground in a near vertical flight path, consistent with a stall. Based on the number of discrepancies observed with the subject engine during the examination consisting of the internal timing incorrectly being set between crankshaft and camshaft by one full tooth, the condition of the camshaft and tappets being severely worn, the engine did not have the potential of making the specified horsepower of 160 BHP at 2700 RPM. There was no evidence of any airframe or control malfunction during takeoff and subsequent crash. 2.3 Human Factors A review of the medical history and clinical findings at last aviation medical examination of the instructor, student pilot and passenger revealed nothing of significance that could reasonably contribute to sudden incapacitation or error of judgment during flight. Post mortem findings of all three victims were consistent with Shock and Haemorrhage, Polytrauma and Multiple Blunt Force Injuries. 2.4 Jamaica Civil Aviation Authority Safety Oversight The lack of written guidance procedures for the certification of Approved Training Organizations (as is the case for Air Operator Certificates) impaired the Flight Safety Divisions ability to evaluate the effectiveness of the ATO’s policies, methods, procedures and instructions as described in its manuals to determine if it had demonstrated its ability to comply with the regulations before beginning its operations. The Flight Safety Division’s procedures did not include any instructions for the inspection of an aircraft and its records prior to the aircraft being added to the ATO’s Operations Specifications (as is the case for Air Operator Certificates).