What happened
On April 30, 2008, an Agusta Westland A-109S, registration PR-IPO, crashed into the sea during a night takeoff from the Condomínio Laranjeiras Helipad (SDLA) in Paraty, Rio de Janeiro. The flight had previously transported passengers from São Paulo to the helipad. After the passengers disembarked, the two pilots attempted a departure bound for Rio de Janeiro.
Seconds after initiating longitudinal movement, the aircraft struck the water surface. The impact resulted in the total destruction of the helicopter and the fatal deaths of both the pilot and the co-pilot.
The investigation
CENIPA's investigation established that the flight was being conducted under Visual Flight Rules (VFR) in meteorological conditions that were not favorable for such operations. The night was characterized by heavy rain and total darkness, with no natural light from the moon or stars.
Investigators found that the crew was operating in a high-workload environment. During the disembarkation of passengers, the pilot on the left seat had left the cockpit to assist with the process, while the pilot on the right seat remained in the cabin, dividing his attention between passenger management and cockpit preparation. Furthermore, the investigation noted that the helipad's takeoff direction was restricted to the sea due to local regulations, which removed any horizon or skyline references.
Findings
- Spatial disorientation was a primary factor, as the crew faced a transition from the illuminated helipad into pitch-black darkness over the ocean, making it impossible to distinguish the sea from the sky.
- The crew failed to reset the Vertical Velocity Indicator (VVI) prior to takeoff, a failure suspected to be caused by fatigue, work overload, and a lack of checklist compliance.
- Flight indiscipline was identified, as the pilots proceeded with a VFR departure despite being in Instrument Meteorological Conditions (IMC).
- Organizational factors, including intense work rhythms and management practices that prioritized schedules over safety, contributed to the crew's degraded situational awareness.
- The lack of adequate airport infrastructure and the presence of unmarked natural obstacles near the takeoff axis further complicated the departure.