What happened
On August 2, 2002, at approximately 23:20 UTC, a Bell 206B helicopter, registration PT-HBV, crashed in the Surucucu indigenous area near Alto Alegre, Roramente. The flight, operated by Caburaí Táxi-Aéreo Ltda., was a nighttime mission intended to rescue an individual in danger near a FUNAI facility.
After departing from the Surucucu aerodrome, the pilot performed a hover near the field. During the subsequent transition, an audible bang was heard, and the aircraft immediately began a descending flight path. The helicopter struck the ground and subsequently collided with trees, resulting in the two fatalities of the pilot and the passenger. The aircraft sustained catastrophic damage to the main rotor, tail rotor, transmission, and hydraulic systems.
The investigation
CENIPA's investigation focused on the pilot's qualifications, the aircraft's maintenance history, and the operational environment. The investigation established that the pilot was operating with expired technical qualifications and an expired medical certificate. Furthermore, the pilot lacked sufficient experience for nighttime operations in a helicopter.
The investigation also examined the aerodrome conditions at Surucucu, noting that the facility lacked runway lighting and was not certified for nighttime operations. Regarding the aircraft, while the airworthiness certificate was valid, the investigation noted that the engine had a history of frequent failures earlier in 2002, including a forced landing in February. The investigation also highlighted organizational issues within the operator, where the pilot acted as the sole owner, administrator, and chief pilot, leading to a lack of managerial oversight.
Findings
- Inadequate flight planning and decision-making: The pilot decided to conduct a flight for which he was neither qualified nor trained, specifically regarding nighttime operations.
- Flight discipline violations: The pilot operated with expired licenses and conducted a nighttime takeoff from an uncertified airfield.
- Environmental factors: The lack of moonlight and poor visibility in the jungle area made maintaining visual flight rules (VFR) extremely difficult.
- Organizational failures: The pilot's centralized management style and high workload contributed to a lack of oversight and potential fatigue.
- Psychological factors: The pilot's high level of self-confidence led to the underestimation of significant operational risks.