What happened
On August 22, 2009, a Cessna T206H amphibious aircraft departed Hamburg-Fuhlsbüttel for a commercial sightseeing flight over Hamburg. Shortly after takeoff, the pilot received instructions from the control tower to turn left immediately to clear the runway for arriving traffic. This instruction interrupted the pilot's climb-out checklist, which included retracting the landing gear.
The flight proceeded toward the Alster and then toward the Elbe river, eventually approaching the Baakenhaert area in the Hamburg Harbor for a water landing. During the approach, the pilot performed a pre-landing check, which included setting flaps and checking various engine parameters. However, the aircraft's landing gear remained in the extended position.
As the aircraft touched the water, the extended wheels caused immediate drag and a high center of gravity, resulting in an instantaneous capsize. The aircraft flipped upside down in the harbor. While the pilot managed to escape the inverted cockpit, the two passengers remained trapped. Despite the pilot's attempts to rescue them, the passengers could not be recovered until rescue divers arrived approximately 40 minutes later. Both passengers died in the accident.
The investigation
The BFU investigation focused on why the landing gear was not retracted following the initial takeoff and why the error was not detected during the approach. Investigators examined the aircraft's configuration, finding the landing gear was in the "Land Down" position. The investigation also reviewed the pilot's experience, the company's checklists, and the cockpit instrumentation.
Key elements examined included the cockpit's landing gear warning system, which was designed to provide an audible alert if the speed dropped below 80–85 knots. Investigators noted that the aircraft had been flying at speeds below this threshold throughout the flight, yet the pilot did not realize the gear was down. The investigation also scrutinized the company's self-made checklist, which lacked specific instructions for verifying gear position for water landings.
Findings
- The primary cause of the accident was the water landing with the landing gear extended.
- The pilot's climb-out checklist was interrupted by air traffic control instructions, leaving the gear unretracted.
- The company's checklist was poorly designed, using a generic "gear – as required" prompt that failed to distinguish between land and water landing configurations.
- The pilot's high level of experience with land-based aircraft may have led to a false sense of security when seeing green indicator lights, which typically signify a correct configuration for land but are incorrect for water.
- The mechanical gear position indicators on the floats were not visible to the pilot during the approach.
- High workload during the short flight duration contributed to the oversight.