What happened
On July 16, 2020, at approximately 13:30 UTC, a Helibras AS 350 B2 helicopter, registration PP-EOW, was conducting a specialized training mission at Aeródromo Estância Machado in Álva/Machado, São Paulo. The mission, operated by the Military Police of the State of São Paulo, was designed to train troops for rapid deployment during prison riots.
The aircraft was performing a low-altitude maneuver at approximately 10 meters when a passenger, part of the tactical team, fell from the aircraft. While the three crew members and three other passengers remained uninjured, the passenger who fell sustained fatal injuries. The aircraft itself sustained no damage.
The investigation
CENIPA's investigation focused on the safety equipment and the operational procedures used during the deployment maneuver. The aircraft was found to be airworthy, with valid documentation and within weight and balance limits. The pilots were qualified and held valid medical certificates.
Investigators examined the safety system, which consisted of a tubular webbing and carabiners designed to anchor personnel to the aircraft floor. While laboratory tests confirmed that the anchoring materials were structurally sound and capable of supporting loads exceeding 120 kgf, the investigation determined that the safety system was not properly attached to the aircraft at the time of the accident.
Furthermore, the investigation revealed that the tactical personnel were positioned on the skids with their bodies facing outward. The investigation found that the crew was following informal practices that had not yet been formalized in the official Standard Operating Procedures (SOP).