Safety study S1/2009L Ultralight Aviation Safety and its Improvement through Accident Investigation Translation of the Finnish original safety study According to Annex 13 to the Convention on International Civil Aviation, paragraph 3.1, the purpose of aircraft ac- cident and incident investigation is the prevention of accidents. It is not the purpose of aircraft accident investiga- tion or the investigation report to apportion blame or to assign responsibility. This basic rule is also contained in the Investigation of Accidents Act, 3 May 1985 (373/85) and European Council Directive 94/56/EC. Use of the re- port for reasons other than improvement of safety should be avoided. Onnettomuustutkintakeskus Centralen för undersökning av olyckor Accident Investigation Board Osoite / Address: Sörnäisten rantatie 33 C Adress: Sörnäs strandväg 33 C FIN-00500 HELSINKI 00500 HELSINGFORS Puhelin / Telefon: (09) 1606 7643 Telephone: +358 9 1606 7643 Fax: (09) 1606 7811 Fax: +358 9 1606 7811 Sähköposti: [email protected] tai [email protected] E-post: [email protected] eller förnamn.slä[email protected] Email: [email protected] or first name.last [email protected] Internet: www.onnettomuustutkinta.fi Henkilöstö / Personal / Personnel: Johtaja / Direktör / Director Veli-Pekka Nurmi Hallintopäällikkö / Förvaltningsdirektör / Administrative Director Pirjo Valkama-Joutsen Osastosihteeri / Avdelningssekreterare / Assistant Sini Järvi Toimistosihteeri / Byråsekreterare / Assistant Leena Leskelä Ilmailuonnettomuudet / Flygolyckor / Aviation accidents Johtava tutkija / Ledande utredare / Chief Air Accident Investigator Markus Bergman Erikoistutkija / Utredare / Air Accident Investigator Tii-Maria Siitonen Raideliikenneonnettomuudet / Spårtrafikolyckor / Rail accidents Johtava tutkija / Ledande utredare / Chief Rail Accident Investigator Esko Värttiö Erikoistutkija / Utredare / Rail Accident Investigator Reijo Mynttinen Vesiliikenneonnettomuudet / Sjöfartsolyckor / Marine accidents Johtava tutkija / Ledande utredare / Chief Marine Accident Investigator Martti Heikkilä Erikoistutkija / Utredare / Marine Accident Investigator Risto Repo Muut onnettomuudet / Övriga olyckor / Other accidents Johtava tutkija / Ledande utredare / Chief Accident Investigator Kai Valonen ____________________________________________________ Translation: R&J Language Service S1/2009L Ultralight Aviation Safety and its Improvement through Accident Investigation ABSTRACT ULTRALIGHT AVIATION SAFETY AND ITS IMPROVEMENT THROUGH ACCIDENT INVESTI- GATION In a relatively short period of time in 2009 there were more serious accidents in Finnish ultralight aviation than in previous years. As a result, Accident Investigation Board of Finland (AIB) began to investigate five ultralight aviation accidents that occurred in 2009. AIB also wanted to establish whether there were any common contributing factors behind ultralight accidents, minor accidents and serious incidents. The primary aim of this study was to research and analyse the human fac- tors that contributed to the occurrences in ultralight aviation. The study was restricted to class B ultralight incidents that the AIB had investigated between 2000–2009. Another aim of the study was to analyse and assess the significance of accident investigation with regard to improvements in ultralight aviation safety. The most important research method used in the analysis of the AIB investigation reports on ul- tralight accidents, minor accidents and serious incidents was the systematic application of the SHELL-model. The research material included altogether 20 investigation reports. To an extent, information in investigation reports was augmented by means of conversations with investigators and the AIB’s archives. The effectiveness of accident investigation on the improvement of ul- tralight safety was mainly researched through the analysis of AIB’s safety recommendations and by interviewing the recipients of said safety recommendations. The development of the present safety level in Finnish ultralight aviation was also established. A further goal of the study was to establish how ultralight accidents and incidents are being investigated in foreign countries. Judging by accident investigation reports and conversations with the investigators, it was the pi- lot’s limited flight experience that contributed to most occurrences. In almost half of the cases the pilot’s poor flying skills and his unsound course of action contributed to the event. Also inade- quate aircraft construction or repair skills and unfavourable weather conditions played a role in many occurrences. Other human factors influencing the occurrences included the pilot’s inade- quate flight training, an inadequate flight manual, substandard aircraft construction, incorrect air- craft loading and the pilot’s poor skills in using cockpit equipment. In one quarter of the examined cases the immediate cause of the occurrence was a stall at low altitude. The pilot failed to recog- nise the symptoms of the approaching stall. On average, ultralight aviation safety improved during the 2000s, on the basis of this study. The research showed that some safety actions concerning ultralight aviation have only been imple- mented as a consequence of accident investigation. Nearly all safety actions have been imple- mented as an outcome of accident investigation but there have also been other contributing fac- tors. This being the case, accident investigation has improved ultralight aviation safety. However, it is very difficult to estimate the level of its impact because there are also many other factors that affect the improvement of ultralight aviation safety. In Finland every ultralight aviation accident and serious incident is investigated. Judging by this study, at least one third of the European countries also investigates ultralight aviation accidents and incidents. I S1/2009L Ultralight Aviation Safety and its Improvement through Accident Investigation TABLE OF CONTENTS ABSTRACT..…………………………………………….………………….…………………………..……I ABBREVIATIONS………………………..........................................................................................VII SYNOPSIS....………………………..…………………..……...................................................……...IX 1 INTRODUCTION .....................................................................................................................1 2 ULTRALIGHT AVIATION HISTORY ........................................................................................4 3 ACTORS IN ULTRALIGHT AVIATION.....................................................................................9 3.1 International bodies ........................................................................................................9 3.2 Finland’s civil aviation authority....................................................................................11 3.3 Finnish Aeronautical Association..................................................................................11 3.4 Accident Investigation Board of Finland .......................................................................12 4 REQUIREMENTS FOR ULTRALIGHT AIRCRAFT ...............................................................14 4.1 Airworthiness................................................................................................................14 4.2 Construction .................................................................................................................16 4.3 Registration and markings............................................................................................18 4.4 Permit to Fly and a Limited Airworthiness Certificate ...................................................18 4.5 Flight operations...........................................................................................................18 5 ULTRALIGHT FLIGHT TRAINING.........................................................................................20 5.1 Ultralight Pilot Licence requirements ............................................................................20 5.2 Ultralight Flight Instructor Rating requirements ............................................................22 5.3 Ultralight flight training organisations............................................................................23 5.4 Ultralight Pilot Licence curriculum ................................................................................24 5.4.1 Theoretical knowledge instruction....................................................................24 5.4.2 Flight training ...................................................................................................27 5.5 Ultralight flight instructor training organisations............................................................29 5.6 Ultralight flight instructor rating curriculum ...................................................................30 6 ACCIDENT STATISTICS IN ULTRALIGHT AVIATION, GLIDING AND MOTOR POWERED GLIDING AS WELL AS GENERAL AVIATION ......................................................................32 6.1 Aircraft and flight hours ................................................................................................32 6.2 Accidents and minor accidents.....................................................................................37 6.3 Fatalities and serious injuries .......................................................................................41 7 ACCIDENTS, MINOR ACCIDENTS AND SERIOUS INCIDENTS IN ULTRALIGHT AVIATION