What happened
On May 2, 2014, an EC120B helicopter, registration PR-FPL, was conducting a training flight at Luziânia Aerodrome (SWUZ) in Goiás, Brazil. The flight crew, consisting of two pilots and one passenger, was performing maneuvers designed to simulate a hydraulic system failure.
During the first circuit, the crew practiced procedures without the aid of the hydraulic system to train the pilot in the right seat. Following this, the aircraft took off again to perform the same training with the pilot in the left seat. During the final approach for the second landing, the aircraft experienced a loss of control in flight and struck the ground approximately 35 meters from the left side of the threshold of runway 11. The impact caused substantial damage to the aircraft, including the rupture of the main rotor blade roots and the disconnection of the tail cone, but all occupants escaped without injury.
The investigation
CENIPA's investigation focused on the circumstances surrounding the loss of control during the simulated emergency. Investigators examined the crew's flight experience, the aircraft's maintenance history, and the organizational framework of the operator, the Federal Highway Police Department.
Technical analysis revealed that while the aircraft had no reported mechanical failures prior to the impact, the crew's execution of the simulated failure was inconsistent with the manufacturer's manual. The investigation also looked into the maintenance records, noting that the aircraft had recently returned to service after being stored for several months as a parts supplier, and identified an unrecorded hydraulic block leak that had been observed since its return to the flight line.
Findings
- Inadequate control skills: The pilot in the left seat had not performed simulated hydraulic failure training for over a year and lacked recent experience in this specific aircraft model.
- Training deficiencies: The absence of a formal, periodic training program led to inadequate motor and cognitive responses during the emergency simulation.
- CRM breakdown: Ineffective Crew Resource Management (CRM) was identified, characterized by a communication breakdown and the abrupt transfer of flight commands between the crew members.
- Organizational failures: The operator lacked standardized operating procedures (SOPs), maintenance programs, and oversight mechanisms to monitor crew proficiency and technical qualifications.
- Managerial oversight: The organization failed to ensure the pilot in the left seat maintained a valid EC20 type rating, which had been overdue since March 2014.