What happened
On December 24, 2005, a Bell 206B helicopter, registration PT-HJJ, was performing passenger transport services between Campo de Marte (SBMT) and a ranch in Atibaia, São Paulo. After completing an initial trip with three passengers, the pilot returned to Campo de Marte to pick up two additional passengers for a second leg to the same destination.
At approximately 23:50, the pilot attempted to depart from the ranch's helipad to return to Campo de Marte. During the takeoff, the aircraft struck the ground roughly 560 meters from the departure point. The impact occurred as the aircraft was traversing an area of rising terrain. The pilot sustained fatal injuries at the scene, and the aircraft was destroyed.
The investigation
CENIPA's investigation focused on the flight's operational legality and the pilot's maneuvers during takeoff. Investigators found that the pilot had filed a flight plan for a different destination (Heliponto Namour) than the one actually used, which was an uncertified helipad at the ranch.
The investigation examined the takeoff technique, noting that the pilot likely attempted a high-performance takeoff to clear perimeter wires. This maneuver involved pitching the nose down to gain airspeed by utilizing a nearby depression in the terrain. Investigators also reviewed the company's management practices, noting a pattern of scheduling night flights to uncertified locations and a lack of adherence to air traffic regulations.
Findings
- Spatial disorientation and visual illusions: The lack of ground references during the night departure likely caused the pilot to misinterpret acceleration as a gain in altitude, leading to a controlled flight into terrain.
- Flight indiscipline: The pilot intentionally provided false destination information to air traffic control.
- Inadequate flight planning: The mission involved significant risks by operating at an uncertified helipad during nighttime hours.
- Management oversight: The operator's management assigned night operations to an uncertified landing site, contributing to the high-risk environment.
- Pilot complacency: The pilot accepted the company's decision to operate in violation of established air traffic rules.
Safety action
CENIPA issued several recommendations, including:
- A recommendation to ANAC to inspect the operator's adherence to safety regulations.
- Instructions for the operator to provide flight safety and physiological training for its pilots.
- A requirement for the operator to update aircraft maintenance logs (cell and engine logbooks).
- The dissemination of the accident findings to all helicopter operators within the jurisdiction to prevent recurrence.