What happened
On July 3, 2008, a Robinson R-22 helicopter, registration PT-HVW, was conducting an aerial news mission over São Paulo, Brazil. The flight departed from Campo de Marte Aerodrome at approximately 20:05 UTC with a pilot and one passenger. While flying over the Pinheiros neighborhood at an altitude of roughly 500 feet AGL, the pilot noticed a sudden fluctuation in the engine RPM.
Misinterpreting this fluctuation as a total loss of engine power, the pilot decided to perform an immediate precautionary landing. The aircraft descended into the São Paulo Cemetery, where the landing was abrupt. During the approach, the main rotor blades struck tree branches, destabilizing the aircraft and causing the left skid to strike the ground heavily. Despite the severe damage to the main rotor, tail cone, and skids, both the pilot and the passenger escaped without injury.
The investigation
CENIPA's investigation focused on the pilot's decision-making and the organizational environment of the aerial news operator. Investigators examined the engine, which was later tested on a test bench and showed no abnormalities. The investigation also looked into the pilot's experience, noting that while qualified, the pilot had only accumulated five flight hours in the preceding four years and had undergone only one training session with the company two days prior to the accident.
Furthermore, the investigation highlighted a lack of effective communication within the cabin. The passenger, a journalist, was using a headset to communicate with a radio station, preventing bilateral intercom communication with the pilot. No pre-flight briefing regarding emergency procedures was conducted for the passenger.
Findings
- Improper decision-making: The pilot incorrectly identified the RPM fluctuation as a power loss and chose an immediate landing rather than following procedures for a governor failure.
- Inexperience: The pilot's limited recent flight experience and lack of familiarity with the specific mission type hindered the correct identification of the technical issue.
- Organizational deficiencies: The operator lacked a robust training program and risk management system, often employing inexperienced pilots for complex urban missions.
- Environmental and operational pressures: High noise levels, low visibility during the evening transition, and the presence of obstacles in the flight path complicated the emergency management.
- Lack of communication: The absence of an intercom connection between the pilot and passenger prevented the transmission of emergency instructions.