What happened
On December 27, 2008, a Robinson R44, registration PP-MCE, was performing a local flight near Cristalina, Goiás, Brazil. The flight was intended to survey a farm owned by the aircraft's owner, with the pilot and the owner on board. The flight was conducted under Visual Flight Rules (VFR) without a filed flight plan.
During the takeoff sequence, the helicopter experienced a sudden, sharp yaw to the left. This movement caused the main rotor blades to strike the ground almost immediately after liftoff, with witnesses noting the aircraft had risen no more and no more than 30cm from the surface. The impact caused severe damage to the engine, main rotor, tail rotor, transmission, and landing gear. Despite the significant structural damage, the pilot and the passenger were uninjured.
The investigation
The CENIPA investigation established that the pilot performed the pre-flight and engine start procedures from memory rather than using the official checklist. Upon inspecting the aircraft after the impact, the pilot discovered that the cyclic friction lock had not been released.
The investigation also revealed that the aircraft's owner had provided deficient supervision by allowing the pilot to perform inspections and checks without the use of a checklist in previous flights. Furthermore, the investigation noted that the aircraft was moved to a maintenance facility in São Paulo before investigators could perform an initial on-site action, which hindered the early stages of the inquiry.
Findings
- The pilot committed a slip or lapse by failing to release the cyclic friction lock, a critical step in the engine start checklist.
- The pilot's habit of performing inspections from memory, rather than using the checklist, contributed to the omission.
- Deficient supervision by the aircraft owner allowed the practice of bypassing checklists to become a routine part of the operation.
- The aircraft was within weight and center of gravity limits at the time of the accident.