What happened
On January 15, 2008, a Bell 407 helicopter, registration PT-YGB, landed at the Piratas Mall helipad in Angra dos Reis, Brazil. The flight had originated from the Lagoa helipad. Upon landing, the pilot did not shut down the engine, leaving it running at idle speed. To assist passengers with disembarking, the pilot applied the cyclic friction lock and exited the cockpit.
During the disembarkation process, the main rotor blades struck two passengers. One passenger suffered a significant injury when part of her scalp was torn by the passing rotor. A second passenger, reacting to the initial accident by reaching toward her head, also sustained superficial hand injuries from the rotor blades. The pilot returned to the cockpit to shut down the engine and provide assistance following the incident.
The investigation
CENIPA's investigation focused on the decision-making process and the operational environment at the helipad. The investigation established that the pilot, while experienced, was performing a private operation (TPP) rather than a commercial air taxi service, and had not received specific training for these types of complementary operations.
Investigators found that the pilot had intentionally positioned the aircraft to one side to protect passengers from the tail rotor, but left the controls unattended. The investigation also noted that the helipad management pressured pilots for quick ground turnaround times, which made engine shutdown difficult due to the time required for subsequent restarts. Furthermore, the lack of trained ground personnel to manage passenger movement contributed to the pilot's decision to leave the cockpit.
Findings
- The pilot's decision to leave the controls while the engine was running and the rotors were in motion was a primary contributing factor.
- A lack of trained ground support personnel to guide passengers during disembarkation increased the risk of rotor strikes.
- Operational pressure to minimize ground time at the helipad discouraged the ideal safety practice of shutting down the engine.
- A prevailing culture among some pilots suggested that securing the controls with friction locks was sufficient to manage safety during passenger movement.
- The absence of a proper briefing for passengers regarding the dangers of the rotor disk area contributed to the incident.