B2/2004L Aircraft accident in Pieksämäki on 16 June 2004

An aircraft accident happened at Naarajärvi of Pieksänmaa on Wednesday, 16 June 2004, about 18.05 Finnish time in which an aircraft OH-CFG of type Cessna A188, operated by Aviation club Joonatan, crashed into ground. The pilot of the plane was seriously injured in the impact. The aircraft was destroyed. Accident Investigation Board Finland set 17.06.2004 by its decision number B 2/2004 L an investigation commission. Investigator Juhani Hipeli was nominated as the investigator-in-charge and aircraft mechanic Hans Tefke as a member of the commission.

When preparing the aircraft for the flight the pilot did not have in his disposal the key for the aircraft doors. He decided to open one door by removing the safety pin like hinge pins of the door lower edge hinges so, that the door was opened from the lower edge. The door closing handle and the padlock were at the upper edge of the door. The intention was to remove the padlock inclusive its mechanisms before the flight, but the tools needed for that were not present at that time. When the pilot had climbed into the cockpit another pilot put from outside the door forward hinge pin partially into place. Initially the pilot only intended to start and test run the engine. After a successful test run the pilot decided to fly the test flight right away. The take-off took place from runway 33 at Pieksämäki airfield. After the initial climb the pilot joined the left downwind leg at an approximate altitude of 600 ft. At the end of a rather narrow downwind leg he extended the flaps to a position of 10 degrees. Having commenced the turn to the base leg the pilot felt the aircraft jerk after which it strongly rolled to the left and the nose pitched downwards. The plane impacted into a ditched marsh in a steep pitch angle and was destroyed. When the safety belts were broken the pilot was slung out through the windshield and was seriously injured.

Although the aircraft was destroyed in the ground impact, practically all parts could be inspected. Both cockpit doors were locked with padlocks. The forward hinge pin of the left door was partially in place, the aft hinge pin was missing altogether. The control system of the plane was intact and the flaps were 10 degrees extended. The engine ignition cables were in bad condition and one spark plug was not operative. The leakage on one of the engine’s cylinders was clearly beyond the maintenance tolerance. The defects have not had noticeable effect on the functioning of the engine. The propeller had been rotating and the engine was probably running at the time of impact. Neither a technical fault, contributing to the accident, nor an indication of malfunction was noticed in the aircraft.

It emerged from the investigation that the pilot set out for the flight unprepared, based on thoughts born during the propagation of the events. The decision was probably influenced both by the time of the early evening and the unstable weather, so that the pressure of the ferry flights, planned for the later evening, caused a feeling of hurry. For this reason the pilot set out for the flight with a plane, to which the door was inadequately fixed. The opinion of the investigation team is that most essential in the pilot’s actions regarding the accident was that the monitoring and control of speed failed due to several factors disturbing the pilot’s action. Besides hurrying there were among other things the opening of the door, inadequate recent experience on the aircraft type, the narrow landing pattern and the strong cockpit noises. The opening of the door probably distracted the pilot’s attention. As a consequence the pilot may have reduced the speed to limit the opening of the door and to shorten the landing pattern to speed up coming into landing. The pilot may have held the door closed with one hand, so that the control of the plane was rendered. The inadequate recent experience and the narrow landing pattern, in which the turn to the base leg must be made steeper than normally, probably rendered holding the attitude and speed of the plane. The strong cockpit noises, typical for the aircraft type, may have given an incorrect impression of the utilized power setting and speed.

The cause of the accident was the reduction of speed, caused by the deficient monitoring and control of speed that led to the loss of control and stall of the aircraft on the base leg of the landing pattern. At the prevailing altitude the pilot could not recover the aircraft from the dive and impact to the ground was inevitable.

The investigation team does not present any safety recommendations.

B2/2004L Report (pdf, 0.96 Mt)