What happened
On May 2, 2013, an AS350BA helicopter, registration PP-EIH, was conducting a weapons training mission at a shooting range in the Caju neighborhood of Rio de Janeiro. The flight involved two pilots and three equipment operators performing takeoff and landing maneuvers for embedded shooting exercises.
During a takeoff maneuver, the aircraft's main rotor blades struck the branches of an almond tree located to the right of the takeoff axis. In an attempt to recover the aircraft, the pilot applied control inputs that caused the helicopter to drift to the left, leading to a second impact between the rotor blades and the metal structure of a nearby building. These successive collisions caused the crew to lose control, resulting in the helicopter striking the ground. The aircraft sustained substantial damage, including broken rotor blades, fuselage twisting, and damage to the tail rotor shaft. While the pilot was uninjured, the co-pilot and one crew member sustained serious injuries, and two other crew members suffered minor injuries.
The investigation
CENIPA's investigation focused on the operational environment and crew performance. The investigation established that the training area was not a standard helipad and lacked defined parameters or standardized procedures for operating in such a restricted space. Investigators found that the takeoff area contained several obstacles and that the area used for landings was small and unmarked.
The investigation also examined the crew's situational awareness and the organizational context. It was noted that while the pilots held valid medical and type-specific certifications, the pilot in command had an expired instrument rating. Furthermore, the investigation looked into the lack of a formal training program specifically designed for operating in these restricted, obstacle-dense environments.
Findings
- Inadequate pilot control inputs led to the secondary collision with the building after the initial strike with the tree.
- Poor crew coordination contributed to the accident, as no verbal warnings were issued by the crew members to the pilot regarding the proximity of the obstacles.
- A fragile safety culture within the organization allowed for the frequent use of informal practices and the continued operation in a high-risk, restricted area without adequate risk management.
- Deficient situational awareness and a failure in judging the necessary separation from obstacles contributed to the rotor blade strikes.
- Inadequate managerial supervision failed to address the latent risks posed by the presence of obstacles in the frequent training flight path.
Safety action
CENIPA issued several recommendations to the National Civil Aviation Agency (ANAC) regarding the operator, the Rio de Janeiro Civil Police, including:
- Improving Crew Resource Management (CRM) training, specifically regarding communication and task definition.
- Enhancing risk management methods within the Safety Management System (SMS), particularly for flight planning in restricted areas.
- Evaluating the use of flight simulators to supplement training for operations in restricted environments.
- Implementing organizational changes to strengthen the culture of compliance with regulatory safety rules.
- Strengthening managerial oversight to ensure operational competence and safety in public security aviation activities.