What happened
On September 20, 2022, an AS350 B2 helicopter, registration PR-SMV, was performing a local flight for a special public security operation at Campo de Marte Aerodrome in São Paulo. The aircraft was carrying five occupants, including two pilots, two aerotactical operators, and one passenger.
During the landing phase, the aircraft experienced a brief loss of altitude, followed by a sudden gain in height and a left yaw. The helicopter completed approximately 270 degrees of rotation before colliding with the ground in a nose-down attitude, leading to a rollover. The impact caused the main rotor blades to be severed at the root and resulted in substantial damage to the cockpit, fuselage, and tail section. Debris from the impact also damaged nearby hangars and parked vehicles. Despite the severity of the impact, all five occupants escaped without injury.
The investigation
CENIPA's investigation revealed that the aircraft was operating above its maximum takeoff weight, and its center of gravity was positioned beyond the forward limit. While the pilots held valid medical certificates and appropriate ratings, the investigation found that the crew did not meet the specific qualification requirements for this type of operation under RBAC 90 regulations. Furthermore, the investigation noted that the unit's last recurrent training involving emergency procedures had occurred approximately three years prior.
Investigators also identified significant organizational deficiencies. The operator lacked a formally established training program, a Safety Management System (SMS), and a standardized system of operational manuals. The investigation also noted that the second in command experienced a reduction in situational awareness, specifically fixating on a perceived hydraulic failure that was not actually occurring.
Findings
- The aircraft was operating above its maximum takeoff weight with an out-of-limit center of gravity.
- The crew lacked the necessary qualifications and training required for the specific operational context.
- The operator lacked essential safety infrastructure, including an active Safety Manager, an SMS, and standardized operating procedures.
- Improper use of flight controls during a high-demand situation aggravated the aircraft's inherent limitations.
- Inadequate organizational planning and a lack of formal safety culture contributed to the crew's inability to manage the flight conditions effectively.
Safety action
CENIPA issued recommendations to the Brazilian National Civil Aviation Agency (ANAC) to ensure the Aerotactical Service of the São Paulo Civil Police develops and implements the required manual systems and a Safety Management System (SMS) as mandated by RBAC 90.