What happened
On February 11, 2019, a Bell 206B helicopter, registration PT-HPG, was performing a passenger transport flight from the Royal Palm Plaza Helipad in Campinas to the Bandeirante Helipad in São Paulo. During the flight, the aircraft experienced an engine failure in flight.
The pilot attempted an emergency landing at the intersection of the Anhanguera (SP-330) and Rodoanel Mário Covas (SP-021) highways. While attempting a self-rotation to land on a grassy area between the highway lanes, the aircraft passed between two viaducts and collided with a truck traveling on an access road. The impact caused the destruction of the helicopter and substantial damage to the truck's cabin. The pilot and the passenger both died at the scene, while the truck driver escaped without injury.
The investigation
CENIPA's investigation focused on the mechanical failure of the engine and the regulatory compliance of the operator. Investigators examined the engine's compressor module and discovered that bearing No. 2 had failed due to insufficient oil flow, caused by a blocked oil delivery tube. The investigation revealed that the oil delivery tube was only half the required length for the passage.
Furthermore, the investigation found significant maintenance irregularities. The engine's compressor module had been reinstalled despite having an expired Time Between Overhaul (TBO) interval. Additionally, records showed that the required intervals for changing engine oil had been exceeded multiple times. The operator, RQ Serviços Aéreos Especializados Ltd., was also found to be operating without the necessary ANAC certification for air taxi services and lacked an approved training program for the specific type of operation being performed.
Findings
- Engine failure caused by the failure of bearing No. 2 due to insufficient lubrication.
- Maintenance non-compliance, including the use of a compressor module with an expired TBO and failure to adhere to oil change intervals.
- Unauthorized operation, as the pilot was performing air taxi services without the required regulatory authorization or operational certification.
- Organizational failures within the operator and the maintenance organization regarding safety culture and oversight.
- Inadequate piloting judgment during the execution of the autorotation and landing maneuver.