What happened
On June 14, 2010, an AS 350 B2 helicopter, registration PT-HZL, was conducting an environmental monitoring mission over Nova Mamoré, Rondônia. The aircraft, operated by IBAMA, was flying with two pilots, two passengers, and one operational crew member.
As the pilot prepared to land in a clearing, the commander executed a high-angle approach to avoid obstacles. To assist with the landing, the crew member requested the cabin door be opened and positioned himself outside the aircraft on the landing skid to monitor ground obstacles. During this maneuver, the crew member fell from the helicopter, resulting in one fatality. The two pilots and two passengers remained uninjured, and the aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the safety equipment and operational procedures used during the landing approach. Investigators examined the crew member's safety gear, finding that he was using a climbing harness and a nylon tie-down strap rather than the manufacturer-recommended "monkey tail" (PN 350 A84-007) safety lanyard. The investigation also noted that the tie-down strap was anchored to a loop on the co-pilot's seatbelt rather than a dedicated aircraft anchor point.
Furthermore, the investigation reviewed the organizational relationship between the flight crew and the operational crew member, noting a lack of standardized communication and training regarding door openings and safety checks. The investigation also found that the co-pilot was not specifically qualified for this aircraft type at the time of the accident.
Findings
- The crew member was not using the manufacturer-specified safety lanyard, instead relying on an improvised system of a climbing harness and a nylon strap.
- The anchoring of the safety strap to the co-pilot's seatbelt was inadequate and improperly executed.
- The lack of standardized cockpit coordination and phraseology meant there was no formal procedure for the pilot to verify the crew member's safety equipment before opening the door.
- There was a lack of operational integration and standardized training between the pilots and the operational crew member regarding safety protocols.
- The crew member was positioned on the skid without the necessity of leaving the cabin, as the procedure should have allowed for monitoring from within the aircraft.