What happened
On June 26, 2015, an EC45 helicopter, registration PR-EES, was engaged in a police support mission near Fortaleza, Brazil. The aircraft, operated by the Coordenadoria Integrada de Operações Aéreas (CIOPAER), had initially departed for a training flight involving rappelling maneuvers. During the flight, the mission transitioned into a real-world police pursuit.
While performing a rappelling maneuver, a crew member became detached from the rope and fell to the ground. The impact resulted in serious injuries to the crew member. The aircraft itself sustained no damage during the incident.
The investigation
CENIPA's investigation revealed several critical operational failures. The crew was in the middle of a training session with a medical emergency team (SAMU) when the mission was interrupted by the police pursuit. During the transition, the pilot had to reposition the aircraft due to rising engine temperatures.
Investigators found that the crew was not properly focused on the maneuver during this repositioning. Furthermore, due to the crew member originally designated for the descent expressing insecurity, another crew member stepped in to take his place. The investigation also noted that the helicopter's internal communication system was incompatible with the helmets being used, and there was a lack of standardized terminology regarding the equipment.
Findings
- Inadequate training: The crew members had not received specific training for rappelling maneuvers in the EC45 model, having previously only practiced in the AS 350 Esquilo.
- Communication failures: Ineffective communication between the crew was caused by incompatible equipment and a lack of standardized call-outs.
- Decision-making errors: The decision to proceed with the rappelling maneuver during a complex police operation was deemed inappropriate given the high-risk environment.
- Organizational pressure: The crew reported a culture of pressure from leadership to execute tasks without room for questioning, even when safer alternatives existed.
- Lack of situational awareness: The crew member performing the descent underestimated the risks associated with the lack of specific aircraft training.