History of Flight:
On 28 September 2021, N6706Y, a 1976 Beech BE-76 Duchess, experienced a prop strike of the left propeller during a training mission at Ramona (KRNM) airport. The left engine required the requisite tear down inspection, along with a new propeller. On that morning, the Private-rated student and Commercial-rated Flight Instructor met at 1000 to teach “preflight review, cockpit/flight controls/procedures/safety brief/taxi brief/emergency brief.” After a lunch break, the student and instructor taxied to 27R at Gillespie Field (KSEE), the departure airport. The run-up was normal and they departed to the East for maneuver practice. After approximately 1.2 hours of maneuver training, they went to RNM for pattern work. The instructor reported that the first landing was done with “little assistance” to power and pitch resulting in a normal landing. The second landing included multiple prompts from the instructor for configuration settings. The instructor stated that the student was rounding off too high and getting slow at which time the instructor said “my flight controls, my airplane.” The student was apparently fixated on the landing and did not relinquish control of the aircraft. The instructor stated they “wrestled over the controls” before the hard landing. They continued the touch and go with the instructor performing the next landing. After several additional touch and goes, they departed back to SEE where they discovered the bent prop during post flight.
Weather at the time of the incident was clear with relatively calm winds at approximately 6 knots. Temperature was 24 C with visibility great than 10 SM.
- The student reported approximately 1,000 hours of flight time with no multi-engine time prior to this flight.
- The instructor also reported approximately 1,000 hours of flight time with approximately 15 hours of flight time in the BE76.
During the investigation a copy of the instructor’s syllabus was requested. The syllabus presented included numerous POH excerpts, system drawings, and multi-engine theory. There were no lesson plans in the instructor’s multi-engine syllabus. During a follow-up discussion, the instructor stated that a schedule is determined based on the student and lesson. The instructor also stated that the first lesson was to cover “instruments, flight controls, review of basic maneuvers, take-offs and landings.” The total flight time was 2.1 with the incident occurring approximately 1.5 hours into the lesson.
The instructor had stated a breakdown in communication during the exchange of flight controls but neglected to perform a full stop after the incident occurred to debrief what had just happen and re-evaluate the next steps. The instructor stated in a follow-up statement that she was feeling anger. The instructor stated that she didn’t feel it was the safest move to request a “emergency stop” to debrief.
The Aviation Instructor’s Handbook discusses the following steps to the risk management process.
- Step 1: Identify the Hazard
- A hazard is defined as any real or potential condition that can cause degradation, injury, illness, death, or damage to or loss of equipment or property. Experience, common sense, and specific analytical tools help identify risks. Once the pilot determines that hazard poses a potential risk to the flight, it may be further analyzed.
- Step 2: Assess the Risk
- Each identified risk may be assessed in terms of its likelihood (probability) and its severity (consequences) that could result from the hazards based upon the exposure of humans or equipment to the hazards. An assessment of overall risk is then possible, typically by using a risk assessment matrix, such an online Flight Risk Awareness Tool (FRAT). This process defines the probability and severity of an accident.
- Step 3: Mitigate the Risk
- Investigate specific strategies and tools that reduce, mitigate, or eliminate the risk. High risks may be mitigated by taking action to lower likelihood and/or severity to lower levels*. For serious risks, such actions may also be taken. Medium and low risks do not normally require mitigation. Effective control measures reduce or eliminate the most critical risks. The analysis may consider the overall costs and benefits of remedial actions, providing alternative choices when possible.
The Aviation Instructor’s Handbook also discusses fatigue in this way:
Fatigue is one of the most treacherous hazards to flight safety as it may not be apparent to a pilot until serious errors are made*. Fatigue can be either acute (short-term) or chronic (long-term). Acute fatigue, a normal occurrence of everyday living, is the tiredness felt after long periods of physical and mental strain, including strenuous muscular effort, immobility, heavy mental workload, strong emotional pressure, monotony, or lack of sleep.
Acute fatigue caused by training operations may be physical or mental, or both. It is not necessarily a function of physical strength or mental acuity. The amount of training any learner can absorb without incurring debilitating fatigue varies. Generally speaking, complex operations tend to induce fatigue more rapidly than simpler procedures do, regardless of the physical effort involved*. Fatigue is the primary consideration in determining the length and frequency of flight instruction periods and flight instruction should be continued only as long as the learner is alert, receptive to instruction, and is performing at a level consistent with experience.
It is important for a flight instructor to be able to detect fatigue, both in assessing a learner’s substandard performance early in a lesson, and also in recognizing the deterioration of performance. If fatigue occurs as a result of application to a learning task, the learner should be given a break in instruction and practice.
A flight instructor who is familiar with the signs indicative to acute fatigue will be more aware if the learner is experiencing them. The deficiencies listed below are apparent to others before the individual notices any physical signs of fatigue.
Acute fatigue is characterized by:
- Errors in timing*
- Neglect of secondary tasks
- Loss of accuracy and control*
- Lack of awareness of error accumulation
Lastly, the Aviation Instructor’s Handbook discusses risk management in relation to instruction below:
Flight instructors need to provide adequate flight and ground instruction for each item included in the applicable ACS/ PTS. The ACS integrates risk management and safety throughout and with supplementary appendix information. PTS lists special emphasis items. Some common items include:
- Positive aircraft control
- Procedures for positive exchange of flight controls
The pilot’s failure to maintain an appropriate airspeed and landing profile. Contributing to the incident was the instructor’s loss of control of the aircraft.