What happened
On September 15, 2010, a Robinson R44 II helicopter, registration PR-DAN, crashed in the municipality of São Félix do Xingu, Pará. The flight was part of a series of movements between local farms. After departing from Fazenda JR at approximately 18:35, the aircraft flew for about 15 minutes before striking a tree at a height of 20 meters, which subsequently led to a collision with the ground.
The accident resulted in four fatalities, including the pilot and three passengers. The aircraft sustained severe damage, rendering it a total loss.
The investigation
CENIPA's investigation focused on the environmental conditions and the decision-making process leading to the flight. Investigators examined meteorological reports from the Amazon Protection System (SIPAM), which indicated unstable atmospheric conditions in the region. High temperatures and low humidity were noted, alongside the presence of smoke from local fires that likely restricted horizontal visibility.
The investigation also scrutinized the pilot's professional environment and the aircraft's maintenance records. While the aircraft was relatively new, with only 242 total flight hours, investigators found that certain Airworthiness Directives (AD) for the engine had not been properly recorded in the aircraft's compliance map. Furthermore, the investigation looked into the psychological and organizational pressures affecting the crew, including the relationship between the pilot and the aircraft owner.
Findings
- Inadequate decision-making regarding flight in restricted visibility and nighttime conditions.
- Improper navigation due to the absence of GPS equipment, causing the aircraft to deviate 130 degrees from its intended course.
- Organizational culture characterized by an authoritarian leadership style, where the pilot felt pressured to execute flights under unsafe conditions to satisfy the employer.
- Environmental factors, including low visibility caused by smoke and clouds, which contributed to spatial disorientation.
- Psychological stress affecting the pilot, stemming from an oppressive work environment and financial pressures.