What happened
On June 26, 2016, a Bell 407 helicopter, registration PR-CBB, departed from Congonhas Aerodrome (SBSP) in São Paulo, bound for Americana, Brazil. The aircraft was carrying one pilot and four passengers. Shortly after takeoff, the helicopter disappeared from radar tracking. Following a search, the wreckage was located the following day in the Serra do Japi region, within the municipality of Jundia/SP. The impact resulted in the destruction of the aircraft and five fatalities.
The investigation
CENIPA's investigation focused on the circumstances leading to the controlled flight into terrain (CFIT). Investigators examined meteorological data, which indicated degraded weather conditions, including low cloud ceilings and visibility issues in the region. The investigation also reviewed the pilot's credentials, noting that while the pilot held a valid medical certificate and type rating, her Instrument Flight Rules (IFR) rating had expired in May 2016.
Technical analysis of the wreckage found no evidence of mechanical failure prior to the crash. Investigators also scrutinized the pilot's medical history, identifying discrepancies in the health inspection process used to obtain the Aeronautical Medical Certificate (CMA). Furthermore, the investigation looked into the possibility of spatial disorientation caused by visual illusions, such as a false horizon, due to the lack of clear visual references in the overcast conditions.
Findings
- Imprecise decision-making regarding the decision to continue flight in unfavorable meteorological conditions.
- Spatial disorientation or visual illusions, potentially triggered by the degradation of weather and lack of external visual references.
- Inadequate altitude management, with the pilot maintaining a flight path close to terrain elevations during adverse weather.
- Organizational flaws in the medical certification process, which allowed for inconsistencies in the pilot's health evaluations.
- Adverse meteorological conditions that likely compromised the pilot's ability to accurately perceive the environment and terrain.