What happened
On January 14, 2019, at approximately 11:0-UTC, a AS 350 BA helicopter, registration PP-ECF, was conducting a routine aerial patrol over major expressways in Rio de Janeiro, Brazil. The mission, operated by the Military Police of the State of Rio de Janeiro (PMERJ), was diverted after the crew received a report of an individual potentially carrying a firearm near the Linha Vermelha highway.
To maintain a defensive posture and avoid potential ground fire, the pilot transitioned to an extremely low-altitude flight profile, flying just above the vegetation along a saltwater canal. The crew performed several low-level passes over the water. During a turn to begin a fourth pass, the aircraft struck the water surface and sank. The impact destroyed the aircraft. Of the four occupants on board, one person sustained fatal injuries, two pilots suffered serious injuries, and one crew member sustained minor injuries.
The investigation
CENIPA investigators examined the aircraft's mechanical condition and the crew's performance. Technical analysis of the engine confirmed it was operational and producing power at the time of the accident. The investigation also focused on the crew's workload and cockpit management.
Investigators found that the pilot in command (PIC) was performing nearly all operational tasks, including flying the aircraft, coordinating with the rear crew, and managing radio communications with air traffic control. The second in command (SIC) was not effectively assisting with these tasks. Furthermore, the investigation noted that the crew's Crew Resource Management (CRM) training was outdated, with the PIC's training having expired and no records found for the SIC. Environmental factors were also scrutinized, specifically the sun's position and its effect on the water's surface.
Findings
- The primary cause of the accident was a failure in crew resource management, specifically regarding the distribution of tasks and cockpit coordination.
- The pilot in command experienced a significant task overload, which degraded operational performance.
- The crew experienced low situational awareness due to the high-stress nature of the mission and the lack of effective task delegation to the second in command.
- Visual depth perception was severely degraded by the sun's position, which caused the calm water surface to become highly reflective (mirror effect).
- The crew was flying at an extremely low altitude, with the aircraft's skids nearly touching the vegetation and water.
- The pilots' CRM training was not up to date according to regulatory requirements.