What happened
On August 5, 2022, at approximately 21:03 UTC, an Agusta A1-09E helicopter, registration PP-JMA, was performing a repositioning flight from the Helicidade Heliport in São Paulo to the Fazenda ACF Heliport in Extrema, Minas Gerais. The flight was intended to pick up a passenger at the destination and was being operated by two pilots.
While cruising through the Serra da Cantareira mountain range in the municipality of Caieiras, the aircraft struck a hill at an approximate speed of 165 knots. The impact destroyed the aircraft, and both crew members sustained fatal injuries.
The investigation
CENIPA's investigation established that the aircraft was operating under Visual Flight Rules (VFR) but had deviated from established flight corridors. The investigation revealed that meteorological conditions were below the minimum requirements for the flight, with a cloud ceiling of only 300 feet reported near the accident site.
Investigators found that no flight plan or notification had been filed for this specific occurrence. Furthermore, a toxicological examination of the pilot in command (PIC) revealed the presence of prohibited psychoactive substances, including cocaine metabolites, clonazepam, venlafaxine, and zolpidem. The investigation also noted that the second in command (SIC) was not formally employed by the aircraft's operator.
Findings
- The primary cause of the accident was controlled flight into terrain (CFIT).
- The pilot in command's use of prohibited psychoactive substances likely impaired cognitive functions, reaction time, and decision-making.
- The crew operated under adverse meteorological conditions, including low ceilings and night flight, which led to the aircraft entering Instrument Meteorological Conditions (IMC).
- The flight demonstrated a practice known as "visumento," involving non-compliance with safety regulations and the use of unauthorized flight routes.
- Inadequate flight planning and a flawed decision-making process contributed to the high-risk operational environment.