What happened
On October 12, 2005, an AS-350 B2 helicopter, registration PP-EPN, operated by the Rio de Janeiro Military Police, was performing a rappelling demonstration at the D. João VI Military Academy. During the exercise, the crew was conducting descents from both sides of the aircraft.
The team failed to notice that the rappelling rope was not touching the ground before the descent began. While one military member noticed the rope felt lighter than usual and halted their descent to investigate, another member continued the descent. This individual eventually disconnected from the line, resulting in a fall from a height of 6.5 meters. The individual sustained serious injuries, while the remaining occupants of the aircraft were unharmed. The aircraft itself sustained no damage.
The investigation
CENIPA's investigation established that several procedural failures occurred during the demonstration. Although a briefing was conducted prior to the flight, investigators could not confirm if the briefing was adequate or if the instructions were fully understood by the participants.
Key findings included a lack of communication regarding the rope's status; the person in charge of monitoring the descent (the 'fiel') did not issue a command confirming the rope had reached the ground, and the pilots did not demand such confirmation. Furthermore, the investigation noted that the military unit lacked written standard operating procedures for rappelling missions and that the crew was not wearing protective equipment, such as helmets, during the operation. The investigation also highlighted a delay in medical assistance, as no medical team or ambulance was stationed at the demonstration site.
Findings
- Lack of coordination in the cockpit: The failure to communicate and verify that the rope was touching the ground allowed the descent to begin at an unsafe altitude.
- Inadequate supervision: The organization lacked written procedures for conducting rappelling and demonstration missions.
- Inadequate instruction: It is probable that the crew had not received sufficient training for this specific type of maneuver.
- Safety equipment omissions: The crew was not utilizing personal protective equipment (PPE), specifically helmets.
Safety action
Following the investigation, several safety recommendations were issued to the Air and Marine Group (GAM), including the implementation of a Crew Resource Management (CRM) program, the mandatory presence of medical teams at all aerial demonstrations, and the creation of standardized written procedures for all flight activities and training requirements.