What happened
On June 14, 2013, a Bell 212 helicopter, registration PR-HRZ, operated by HRT Oil & Gas, crashed approximately 0.6 nautical miles from the Porto Moura support base in Tefé, Amazonas. The flight was intended to transport a passenger from the support base to a different location.
Shortly after takeoff, the aircraft encountered severe weather conditions. The flight lasted only five minutes before the helicopter collided with treetops at a 45-degree left inclination and subsequently struck the ground with a 90-degree left tilt. The impact caused substantial damage to the aircraft's structure and rotating system. Both the pilot and the passenger sustained fatal injuries at the scene.
The investigation
CENIPA's investigation focused on the environmental conditions and the pilot's decision-making process. Meteorological analysis revealed that the area was experiencing heavy fog and overcast skies, with horizontal visibility restricted to approximately 150 meters and vertical visibility near 100 feet. These conditions were highly unfavorable for Visual Flight Rules (VFR) operations.
The investigation examined the pilot's qualifications and the company's operational culture. While the pilot was highly experienced, his Instrument Flight Rules (IFRH) qualification had been expired since March 2011. Furthermore, the aircraft was not approved for instrument flight. Investigators also looked into the organizational climate, noting a lack of formal flight supervision and a company culture where deviations from safety rules were common.
Findings
- Spatial disorientation was the primary cause of the accident.
- The pilot demonstrated overconfidence and poor judgment by deciding to take off in adverse weather despite a prior agreement to wait for weather updates.
- The pilot's IFRH qualification was expired, and the aircraft was not equipped or approved for IFR operations.
- Inadequate flight planning occurred, as the pilot lacked sufficient weather information for the route.
- Organizational factors contributed to the risk, including a lack of flight engineers to advise on critical decisions and a lack of formal training/monitoring systems for pilots.
- The company lacked a local weather station, forcing pilots to rely on internet-based forecasts which were unavailable at the time of the flight.