What happened
On April 16, 2007, an AS350BA helicopter, registration PP-EIO, operated by the Military Police of Espírito Santo, crashed near the district of Barbados, approximately 12 km from Colatina. The aircraft was performing a return flight from Colatina to Vitória to transport harvested organs, including kidneys and corneas, back to the medical team.
The flight originated from Vitória on the night of April 15, 2007. After an initial delay due to heavy rain and the late arrival of the medical team, the aircraft landed at a municipal stadium in Colatina. The crew remained with the aircraft while the medical team performed the organ retrieval. The return leg began at 03:00 UTC on April 16. Approximately ten minutes after takeoff, the aircraft struck the ground, resulting in six fatalities (two pilots and four passengers). The aircraft was completely destroyed.
The investigation
CENIPA's investigation examined the operational sequence, meteorological conditions, and organizational management of the NOTAER unit. Investigators reviewed the flight planning, the crew's fatigue levels, and the decision-making process regarding the night flight under marginal weather conditions. The investigation also looked into the lack of standardized procedures for civil defense aerial operations and the adequacy of crew rest facilities during mission delays.
Findings
- Adverse meteorological conditions: The presence of clouds and low visibility contributed significantly to the accident.
- Flight planning failures: The crew did not adequately analyze the risks associated with the mission, including the impact of the delayed departure and the extended work shift.
- Management oversight: The organization lacked standardized procedures for decision-making in adverse weather and failed to provide adequate rest areas for crews during mission delays.
- Flight indiscipline: The takeoff was conducted under conditions that violated VFR requirements, as the aircraft was not certified for IFR operations.
- Environmental factors: The darkness of the night hindered visual references.
- Crew fatigue: The extended working hours and the lack of proper rest contributed to the operational risks.
- Inadequate supervision: There was a lack of periodic training and a failure to implement effective risk management methods.