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ASN Wikibase Occurrence # 247575
Last updated: 1 December 2021
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Date:07-FEB-2021
Time:15:31 LT
Type:Silhouette image of generic C150 model; specific model in this crash may look slightly different
Cessna F150G
Owner/operator:Blue Skies Aviation
Registration: OH-DBS
MSN: F150-0125
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Asikkala Vesivehmaa-airport EFLA -   Finland
Phase: Landing
Nature:Training
Departure airport:Lahti-Vesivehmaa (QLF/EFLA)
Destination airport:Lahti-Vesivehmaa (QLF/EFLA)
Investigating agency: SIAF
Narrative:
In a wintry afternoon on February 7, 2021, a student pilot and his instructor were conducting a touch-and-go in a Cessna 150 airplane at Lahti-Vesivehmaa aerodrome. The cloudy weather and snow-covered runway combined to make the edges of the runway difficult to discern. To compensate for right crosswind, the airplane was crabbed to the right, and crab was maintained on touchdown. During the ground run, the instructor focused on monitoring the flap position indicator, and neither pilot was aware of the airplane’s drift to the right. Neither pilot took action to decrab the airplane, and as a result the airplane hit a snow bank bordering the right edge of the runway and ended up inverted. There were no injuries, but the airplane was damaged beyond repair.
Vehicles proceeded onto the runway after the accident. Clearing of the accident site was begun before the occurrence was reported to an air traffic services unit and the Safety Investigation Authority Finland. Two airplanes approached the aerodrome while this work was in progress. The pilot of the first airplane observed vehicles and people on the runway but estimated that sufficient clearance was available for a safe landing. The pilot of the second airplane elected to delay landing until the runway was clear.

CONCLUSIONS
Conclusions encompass the causes of an accident or a serious incident. Cause means the different factors leading to an occurrence as well as relevant direct and indirect circumstances.
1. The LAPL(A) student had completed only a small part of theoretical knowledge instruction before starting the flight instruction phase, and this deficiency existed throughout the early phase of flight instruction. There are no requirements for theoretical knowledge instruction to be completed prior to the commencement of flight instruction.
Conclusion: The approved training organization did not ensure that the student had sufficient theoretical knowledge before starting flight instruction. Moving to the flight instruction phase without sufficient theoretical background does not support the attainment of desired learning objectives and increases risk levels.
2. Flight instruction did not follow the recommended order laid down in the training syllabus. The instructor decided the order of the exercises. Basic skills needed during touch-and-goes had not been practised.
Conclusion: The own-check procedures of the approved training organization were not applied successfully in flight instruction. Deviation from the order of air exercises laid down in the training syllabus and postponing air exercises containing takeoffs and landings until after touch-and-go exercises increases risk levels.
3. The characteristics of the accident airplane, runway availability, winter conditions and touch-and-goes all combined to present increased challenges to the student who was practising landings and takeoffs.
Conclusion: Touch-and-goes are conducted during flight instruction to minimize flight hours and costs. Local conditions were not given sufficient consideration during initial flight instruction.
4. Task-sharing between the pilots was inconsistent during the flight and was not clear during the touch-and-go that led to the accident, which resulted in a situation where neither pilot was controlling the airplane during the ground run.
Conclusion: Unclear task-sharing or ambiguous communication are often cited as probable causes of aviation accidents. During flight instruction it is particularly important to assign tasks that should be carried out by the instructor and by the student during all phases of the flight, and the related communication procedure should be known in detail by both pilots.
5. The instructor did not notice the airplane’s drift towards the edge of the runway since he was operating the flap select switch and was focused on monitoring the flap position indicator.
Conclusion: Loss of situational awareness often results in a hazardous situation or an accident. Situational awareness can be lost when the crew member feels rushed, under demanding conditions, or when he or she becomes fixated on a single matter or on anything that is secondary in the prevailing situation.
6. Risk management actions related to runway excursions did not sufficiently address conditions on an uncontrolled aerodrome. These actions were neither put into practice nor included in the manuals of the approved training organization.
Conclusion: Risk mitigation actions will lead to a desired effect only when they are presented in an unambiguous manner, are measurable and are included in operational procedures.
7. The emergency response plan of the approved training organization was not adhered to after the accident. Deficiencies were noted in the plan, which had not been tested in exercises.
Conclusion: The emergency response plan of the approved training organization had not been assimilated.
8. Persons converged at the accident site. Some of them drove vehicles onto the runway. No notification was made on an aeronautical radio frequency about the fact that the runway was occupied, and no consideration was given to arriving traffic. Another airplane landed on the occupied runway.
Conclusion: Failure to notify of an accident or an occupied runway may put the safety of other aviators in jeopardy and lead to further damage.
9. The airplane was moved from the accident site and components were removed before the occurrence had been reported to an air traffic services unit and the Safety Investigation Authority Finland.
Conclusion: Regulations are not known, or they are disregarded. Unauthorized clearing of an accident site will undermine the conditions of an on-site safety investigation.
10. Own-checking in the approved training organization was insufficient. The organization did not always adhere to its internal instructions. Continued airworthiness management was entrusted to a partner. Discrepancies in the documents of the airplane remained unnoticed.
Conclusion: Deficiencies existed in the safety management system of the approved training organization.

Sources:

https://www.mtvuutiset.fi/artikkeli/lentokone-lensi-lumipenkkaan-asikkalassa-kaksi-kyydissa-ollutta-tarkastettiin/8058264#gs.sbfmmg
https://www.is.fi/kotimaa/art-2000007788845.html
https://twitter.com/phpelastus/status/1358421058769018880
https://www.hs.fi/kotimaa/art-2000007788888.html
http://www.lentoposti.fi/uutiset/otkes_k_ynnist_turvallisuustutkinnan_vesivehmaalla_koulukoneelle_tapahtuneesta_lentoturmasta
https://www.ess.fi/paikalliset/3594867
https://turvallisuustutkinta.fi/en/index/currentissues/releases/2021/l2021-01thelossofcontrolofanaircraftduringalandingrunonatrainingflightatthelahti-vesivehmaaairporton7february2021.html
https://turvallisuustutkinta.fi/fi/index/tutkintaselostukset/ilmailuonnettomuuksientutkinta/tutkintaselostuksetvuosittain/2021/l2021-01koululennollaolleenlentokoneenajautuminenuloskiitotieltalapilaskussalahti-vesivehmaanlentopaikalla7.2.2021.html
http://www.lentoposti.fi/uutiset/otkes_oppilas_lensi_koulutukseen_ja_taitotasoon_n_hden_liian_vaativissa_talviolosuhteissa
https://turvallisuustutkinta.fi/en/index/tutkintaselostukset/ilmailuonnettomuuksientutkinta/tutkintaselostuksetvuosittain/2021investigations/l2021-01runwayexcursionduringtouch-and-gooninstructionalflightatlahti-vesivehmaaaerodromeonfebruary72021.html

Accident investigation:
cover
  
Investigating agency: SIAF
Status: Investigation completed
Duration: 8 months
Download report: Final report


Images:

Photo of OH-DBS courtesy AirHistory.net


Helsinki - Malmi (EFHF / HEM)
7 May 2020; (c) Pertti Sipilä

Revision history:

Date/timeContributorUpdates
07-Feb-2021 14:48 Dolly564 Added
07-Feb-2021 14:49 harro Updated [Aircraft type, Departure airport, Narrative]
07-Feb-2021 15:08 Dolly564 Updated [Phase, Destination airport, Source, Narrative]
07-Feb-2021 17:52 gerard57 Updated [Narrative]
07-Feb-2021 19:53 Dolly564 Updated [Source]
08-Feb-2021 10:12 Dolly564 Updated [Narrative]
11-Feb-2021 17:37 harro Updated [Source]
12-Feb-2021 17:58 Dolly564 Updated [Nature, Source, Narrative]
12-Oct-2021 12:24 Dolly564 Updated [Source]
12-Oct-2021 12:29 harro Updated [Damage, Narrative, Accident report]

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