B6/​2009L Ul­tra­light air­craft ac­ci­dent at Kauhava aero­drome on 4 Au­gust 2009

16.06.2010

An accident happened at 19:08 on Tuesday, 4 August 2009 at Kauhava aerodrome. An EV-97 Eurostar, Class B ultralight aircraft was on a training flight when it collided with the ground. The aircraft was destroyed and both persons in the aircraft were killed instantly. On 10 August 2009, Accident Investigation Board of Finland appointed investigation commission B6/2009L for this accident. Investigator Juhani Hipeli was named investigator-in-charge, accompanied by investiga-tors Timo Kostiainen and Erja Savela. Investigator Olli Borg was appointed as an expert to the commission.

On the accident flight, one of the topics being practiced was an emergency landing after engine failure following takeoff. The intention was to turn back and land on the runway in the opposite direction of the takeoff. The simulated engine failure was initiated at 350 feet (107 m) AGL. As soon as the engine was set to idle, they started a descending turn towards the right, into a head-wind. During the early phase of the turn the aircraft lost a lot of height. During the final it also lost so much airspeed that the student flight instructor, who, as far as the investigation commission knows, was flying the aircraft, lost control of the aircraft. As a result, the aircraft abruptly rolled to the right and went into an increasingly steep dive, colliding with the ground in a nearly vertical attitude.

The student flight instructor was inexperienced with regard to the planned emergency landing manoeuvre. Moreover, based on his training, he did not have the required competence to fly the known to be difficult manoeuvre. The investigation especially focused on why this particular, often accident-prone, emergency landing manoeuvre was being practiced at all. A safer, and generally recommended, way of executing an emergency landing after takeoff is to land in the sector ahead. The investigation revealed that, in ultralight flight instructor training, such emergency land-ings during which one turns back to the runway were to be demonstrated to the students. Since the flight syllabus in use does not specifically define the content of instruction, extremely diverse instructor-specific practices had emerged in flight instructor training. The investigation also re-vealed that Aviation Regulation PEL M2-71, determining the rights of the ultralight student flight instructor, was being interpreted in varying ways by flight clubs that provide ultralight flight train-ing. It is the opinion of the investigation commission that an ultralight student flight instructor rat-ing did not qualify the student flight instructor to act as a flight instructor on the accident flight.

The accident was caused by inadequate flight instrument monitoring while turning back towards the runway, i.e. during a technically demanding manoeuvre. When the airspeed bled off during the turn, the aircraft stalled, resulting in a loss of control. Upset recovery was not possible be-cause of the low altitude. Contributing factors include the prevailing culture in ultralight flight train-ing, in which some flight training organisations or individual flight instructors have instructed stu-dents in abnormal and emergency procedures training to turn back towards the movement area in conjunction with simulated engine failures at takeoff, even from very low altitudes. Flight training syllabi do not include instructions for such a manoeuvre. During the accident flight the student flight instructor’s flight experience and flight currency with regard to flying or teaching turn-backs towards the runway were insufficient.

The investigation commission issued six safety recommendations; three to Trafi Aviation (the Finnish aviation authority), two to the Finnish Aeronautical Association as well as one joint rec-ommendation to Finavia Corporation and the Emergency Response Centre Administration.

Trafi Aviation was urged to clarify the Aviation Regulation PEL M2-71 ultralight student flight in-structors’ rights, so as to make them unambiguous. The second recommendation was that Trafi Aviation lead the preparation of written proficiency standards for the instructors of sport aviation flight instructor courses, and that opportunity for training which provides such proficiency be ar-ranged. Thirdly, it was recommended that Trafi Aviation take action against flying with aircraft exceeding the maximum takeoff weight.

The Finnish Aeronautical Association was encouraged to lead a process in which the syllabi of ultralight pilots and flight instructors would be made more detailed, and that instructions on how to fly manoeuvres as well as vital safety limits and goals for learning be included in the curricula. Secondly, it was recommended that the Finnish Aeronautical Association prepare written guide-lines for the flight instructors that supervise student flight instructors in sport aviation.

The following joint recommendation was given to Finavia Corporation and the Emergency Re-sponse Centre Administration: When it comes to cooperation between Emergency Response Centres and Rescue Co-ordination Centres, Finavia Corporation and the Emergency Response Centre Administration are advised to update their mutual measures and instructions related to air accidents. A corresponding recommendation was issued on 15 January 2010 with regard to the B2/2009L investigation.

Other related content