What happened
On October 19, 2009, a Schweizer 269C-1 helicopter, registration PR-SCO, was conducting a patrol flight for the Alagoas State Secretariat of Social Defense (DIOPAER). The aircraft departed from the Alagoas State Government Palace at 15:20 UTC with two pilots on board.
Approximately 30 minutes into the flight, while operating near the Maceió (SBMO) aerodrome, the engine stopped due to fuel exhaustion. The pilot was forced to perform an emergency landing in an open field. During the approach to the landing site, the helicopter struck a wall, causing the aircraft to tip onto its left side. The impact resulted in severe damage to the airframe and partial destruction of the wall, though the two crew members sustained only minor injuries.
The investigation
CENIPA's investigation focused on the operational and organizational environment of the DIOPAER unit. Investigators examined the aircraft's maintenance records, which showed that while the airworthiness certificate was valid, the aircraft had previously flown with expired inspections. The investigation also looked into the management of the flight logs and the administrative burden placed on the flight crew.
Investigators found that the pilots were heavily burdened with administrative, maintenance, and flight safety duties, which likely reduced their risk perception. Furthermore, the investigation highlighted a lack of effective supervision and a lack of standardized briefing/deverbriefing procedures within the organization.
Findings
- Inadequate fuel monitoring: The primary cause was the lack of proper control over the aircraft's logbook, specifically regarding the timely recording of flight hours and fuel consumption/replenishment.
- Management planning failures: The Secretariat of Social Defense failed to allocate sufficient material and human resources to support the operational and maintenance needs of the unit.
- Organizational oversight: There was a lack of effective supervision by the Secretariat regarding the technical and operational activities of the DIOPAER.
- Administrative overload: The accumulation of administrative tasks by the pilots contributed to a diminished perception of operational risks.
- Maintenance concerns: The reliance on maintenance services provided by an out-of-state company created pressure on mechanics to complete work quickly, leading to distrust among the crew.