What happened
On 13 June 2007, a Bell-212 helicopter, registration EC-FBM, operated by Helisureste, was performing a positioning flight from Santander Airport to Mutxamiel Aerodrome via Teruel. The flight was initially conducted under visual flight rules (VFR), following a route through the Ibaizabal River valley and toward Pamplona.
As the aircraft approached the town of Oñati, visibility began to deteriorate. The crew performed a 180-degree turn to return along their original route, but subsequently entered the Araotz River valley. Upon entering the valley, the helicopter penetrated a layer of fog, resulting in instrument meteorological conditions (IMC). Shortly after the transition to instrument flight, the aircraft impacted a hillside at an elevation of 2,280 ft. Both the pilot and copilot were deceased.
The investigation
The CIAIAC investigation examined the flight preparation, navigation methods, and the crew's response to deteriorating weather. The investigation focused on the use of GPS as the primary navigational tool and the crew's decision-making when encountering fog. Investigators also analyzed the cockpit voice recorder (CVR) to evaluate crew resource management and the transition from VFR to IMC.
Findings
- The flight plan preparation failed to adequately study the terrain or select routes better suited to the forecasted weather.
- The crew initiated the flight under VFR despite weather forecasts indicating the potential for reduced visibility.
- The pilots had little to no experience flying in the Cantabrian Range.
- Navigation relied heavily on GPS, which led the crew toward a direct route rather than utilizing safer, lower-altitude mountain passes.
- The captain knowingly entered IMC conditions within Class G airspace where ground obstacles were present.
- Once in IMC, the crew failed to execute a controlled maneuver to reach the minimum en route altitude (MEA) or return to visual conditions.
- There were deficiencies in crew resource management, including a lack of coordination during course changes and a failure by the copilot to challenge the risks of the chosen path.