What happened
On February 16, 2006, a Robinson R44 helicopter, registration PR-JAC, crashed in the Santa Paula II neighborhood of Vila Velha, Brazil. The flight originated from the João Monteiro Aerodrome with the intention of picking up a passenger in Serra.
Prior to departure, the pilot performed the pre-flight procedure, which included installing the cockpit pedals that had been removed the previous day for maintenance. During the flight, shortly after takeoff, the aircraft began an uncontrolled left yaw. In an attempt to correct the deviation, the pilot reduced power and airspeed, which inadvertently increased the leftward yaw tendency. The aircraft entered a spin and eventually struck the ground with a significant lateral tilt and nose-up attitude. The impact resulted in the total destruction of the aircraft, though the pilot survived with minor injuries.
The investigation
CENIPA's investigation focused on the sequence of events leading to the loss of control. Investigators determined that the pilot had installed the left and right pedals in an inverted configuration. Because the pedals were swapped, the left pedal acted as a physical stop for the right pedal, preventing the pilot from applying enough right pedal input to counteract the torque changes during power reduction.
The investigation also noted that the pilot was under pressure to depart quickly due to a delay and a phone call from the aircraft owner. During the pre-flight inspection, the pilot was interrupted by refueling personnel and subsequently skipped the checklist item intended to verify the free movement of the pedals. Furthermore, the investigation found that the aircraft's manual did not clearly warn against the risks of inverted pedal installation, nor did it provide specific instructions to prevent such an error.
Findings
- The pilot installed the flight pedals in an inverted position.
- The inverted installation caused the left pedal to obstruct the full travel of the right pedal.
- Improper pedal installation prevented the pilot from countering the leftward yaw caused by reduced engine torque.
- The pilot's decision to reduce power and airspeed during the yaw event exacerbated the loss of control.
- The pilot failed to complete the checklist item verifying pedal movement due to an interruption and time pressure.
- The aircraft's manual lacked sufficient clarity regarding the risks of incorrect pedal assembly.
- The pilot's limited experience with rotary-wing aircraft contributed to the inability to recognize and correct the situation through power increases.