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ASN Wikibase Occurrence # 150578
Last updated: 25 May 2018
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Date:08-NOV-2012
Time:ca 19.08 EET
Type:Silhouette image of generic C206 model; specific model in this crash may look slightly different
Cessna 206H Stationair
Owner/operator:Private
Registration: OH-AAA
C/n / msn: 20608214
Fatalities:Fatalities: 1 / Occupants: 1
Other fatalities:0
Airplane damage: Written off (damaged beyond repair)
Location:Puntarikoski, near Kontiolahti, 2 km from EFJO -   Finland
Phase: En route
Nature:Private
Departure airport:EFJO
Destination airport:EFLP
Narrative:
A Cessna 206H dual-purpose amphibian aircraft, registration OH-AAA, collid-ed with the ground on a cross-country flight from Joensuu airport to Lappeenranta and was destroyed. The pilot perished in the accident.

On the day of the accident it was snowing off and on at Joensuu airport. The meteorological conditions permitted night-VFR flying in the control zone. Just as OH-AAA was about to take off the weather conditions deteriorated significantly. Upon noticing this, the pilot expedited his take-off and cancelled the planned refuelling.

The air traffic controller issued a clearance for a special VFR flight, and for a controlled special VFR flight directly towards Lappeenranta, and cleared the aircraft for take-off from RWY 10. By 18:58, the moment of take-off, the snow had intensified but visibility was still better than the re-quired 3 km, the cloud base was at 3900 ft. In contrast, the General Area Forecast (GAFOR) weather class for the en-route segment of the flight to Lappeenranta predicted that visibility would remain over 5000 m and cloud base above 1000 ft, whereas the minimum requirements are 8000 m and 2000 ft, respectively. Following the take-off the aircraft started to turn to right, towards Lappeenranta.

Soon after the take-off the air traffic controller tried to contact the aircraft several times so as to get a position report from the pilot. However, there was no reply. Therefore, the controller raised the airport’s rescue readiness and declared a local standby phase.

At 19:08:50 the Emergency Response Centre (ERC) of North Karelia received a phone call from an eyewitness who reported having seen an aircraft flying towards Kyyrönsuo Marsh at an ex-tremely low level a few minutes earlier. At the moment of the observation it was snowing extremely hard. Approximately 10–30 seconds after the observation the eyewitness heard a sound that resembled a collision with the ground, following which it became quiet. The aircraft had collided with trees in the Kyyrönsuo Marsh peat production area, following which it hit the ground at an approximately 30° angle, banked 110–120° to the left.

The investigation focused on establishing the aircraft’s technical airworthiness, evaluating the effects of the meteorological conditions, and human factors.

While the meteorological conditions at the time of take-off permitted the initial phase of the flight to the control zone as per a special VFR clearance, the heavy snow shower that entered the area reduced visibility to below 2 km. The en-route weather conditions did not meet the minimum requirements for a night-VFR flight. The aircraft had iced up on the ground before the take-off and this may have led to difficulties in controlling the aircraft.

The worsening weather conditions and the need to complete the flight during that evening caused the pilot to rush with the take-off and cancel the planned refuelling. Had the aircraft been refuelled, the pilot may have noticed the ice on the top surface of the wings. Because of the delay caused by refuelling and clearing the ice off the wings the take-off would also have been delayed. The snow shower would also have moved to the east, away from the airport area, and the accident would probably have been avoided. Haste affected the pilot’s capacity to evaluate the risks associated with the conduct of the flight. Due to insufficient horizontal visibility the pilot became spatially disoriented and lost control of the aircraft in a turn made at a low altitude and in heavy snow.

The root cause of the accident was the pilot’s decision to take off into excessively demanding meteorological conditions. Haste and biases, typical to humans, degraded the pilots ability to evaluate the risks associated with the conduct of the flight.

The direct cause of the accident was probably the pilot’s spatial disorientation and loss of control of the aircraft, as a result of which the aircraft collided with the ground. Also, loss of control caused by wing icing cannot be excluded.

Contributing factors included the pilot’s limited night flying experience as well as inadequate re-cent flight proficiency, especially with a Cessna 206 aircraft.

The investigation issued three safety recommendations.

Safety Investigation Authority, Finland (SIAF) recommends that the Finnish Meteorological Insti-tute augment its Finnish Meteorological Services publication weather card (the so-called “weath-er accordion") by adding a note to section “GAFOR" which states that weather class “O" does not necessarily permit night-VFR flying outside aerodrome control zones or beyond the landing pattern of an uncontrolled airstrip.

SIAF recommends that the EASA study the possibility of drawing up a proposal for a standard which would suggest that all GPS devices intended for use in aviation have a function that rec-ords the parameters of the route flown. Moreover, the memory of such devices should not require a power source to retain the stored data. A similar safety recommendation was already issued in 2009, in conjunction with Investigation Report B3/2008L.

SIAF recommends that Finavia Corporation amend the cooperation arrangement between the Aeronautical Rescue Co-ordination Centre Finland (ARCC Finland) and airports’ ATS units by clarifying the definition of their respective areas of responsibility.

This is one of 8 accidents that resulted in an EASA rule making team on in-flight recording for light aircraft.

EFJO 081750Z 26008KT 230V290 9999 -SHSN FEW010 SCT034 BKN039 M01/M02 Q0994=
EFJO 081650Z 26006KT 220V290 9999 -SHSN FEW010 SCT034 BKN039 M01/M01 Q0993=

Sources:

http://www.iltalehti.fi/uutiset/2012110816307548_uu.shtml
http://jetphotos.net/showphotos.php?regsearch=OH-AAA
http://www.turvallisuustutkinta.fi/material/attachments/otkes/tutkintaselostukset/fi/ilmailuonnettomuuksientutkinta/2012/J4EZkQHPD/Tutkintaselostus_L2012-10.pdf
http://aerossurance.com/helicopters/easa-launch-rule-rumaking-team-flight-recording-light-aircraft/


Images:


Revision history:

Date/timeContributorUpdates
08-Nov-2012 13:17 Penu Added
09-Nov-2012 09:27 Penu Updated [Time, Aircraft type, Registration, Cn, Location, Narrative]
10-Nov-2012 11:08 Penu Updated [Time, Source]
15-Nov-2012 11:23 Penu Updated [Narrative]
03-Aug-2013 11:59 Anon. Updated [[Narrative]]
23-Jan-2014 19:19 harro Updated [Source]
02-Aug-2014 14:05 Aerossurance Updated [Narrative]
03-Aug-2014 06:25 Aerossurance Updated [Source, Narrative]
17-Apr-2017 17:34 Anon. Updated [Narrative]

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