What happened
On March 16, 2022, an S-76C++ helicopter, registration PR-LCT, was performing an offshore passenger transport flight from Salvador, Bahia, to the Manati Maritime Platform (9PMM) in the Camamu Basin. The flight was being conducted under Visual Meteorological Conditions (VMC).
During the final approach for landing on the platform, the aircraft experienced an excessive increase in its rate of descent. This loss of control led to a collision with the sea surface. The impact caused substantial damage to the aircraft's main rotor, tail rotor, radome, windshield, and fuselage, as well as internal engine damage. The Pilot in Command (PIC) sustained fatal injuries, while the Second in Command (SIC) and eleven passengers suffered minor injuries.
The investigation
CENIPA's investigation focused on the circumstances leading to the loss of control during the approach. The investigation examined the flight crew's recent experience, the training environment, and the company's managerial oversight. Investigators analyzed the flight recorder data and reviewed the operational procedures for training flights involving the SIC, who was occupying the right-hand seat for the first time since being hired by the operator.
Findings
- The investigation identified a failure to conduct specific briefings for the flight, as it was a training-related mission where the SIC was acting as Pilot Flying in the right-hand seat.
- There was evidence of a flaw in managerial oversight, noting that it had become a recurring practice among flight instructors to omit specific briefings for such flights.
- The investigation noted that the SIC was performing his first enroute flight of the fortnight working period and his first time in the right-hand seat under evaluation.
- The investigation also considered that the use of an emergency compressed-air breathing system might have improved the pilot's chances of escaping the submerged aircraft.
Safety action
Following the investigation, several safety recommendations and actions were identified:
- ANAC was advised to evaluate the implementation of best practices regarding Helicopter Underwater Escape Training (HUET), the use of compressed-air emergency breathing systems (CA EBS), and Personal Locator Beacons (PLB) for offshore flights.
- Recommendations were made to improve Crew Resource Management (CRM) techniques, specifically regarding cross-checks and coordination during final approaches to helidecks.
- The operator updated its crisis management checklists, emergency response plans, and internal procedures for flight-crew evaluations and psychological profiling.