What happened
On September 23, 2015, a Bell 206L-3 helicopter, registration PP-ELA, operated by the Government of the State of Alagoas, was conducting a training flight and a low-altitude overflight of Maceió. The flight departed from Maceió International Airport (SBMO) for training at the Aeroclube de Alagoas (SNGS).
During the flight, the aircraft entered a left-hand turn at an altitude of approximately 10 meters. During this maneuver, the helicopter's main rotor blades struck low-voltage power lines. The impact caused the aircraft to lose control, leading the left skid to strike the ground, which subsequently caused the rear of the skid to impact the terrain. The aircraft was destroyed by the impact and subsequent fire, which also destroyed a parked vehicle nearby. All four occupants (three crew members and one passenger) died at the scene.
The investigation
CENIPA's investigation examined the flight dynamics, the crew's qualifications, and the organizational environment of the operator. Investigators analyzed the aircraft's maintenance records, which showed the 100-hour inspection had been completed only 13 hours prior to the accident.
The investigation also looked into the psychological and professional state of the crew. The pilot was undergoing significant personal stress due to a marital separation, and the occupant in the front left seat was a helicopter pilot who lacked the specific type rating for the Bell 206L-3. Investigators also scrutinized the organizational culture of the operator, noting a lack of formal operational manuals and a high degree of informality in flight supervision and training procedures.
Findings
- Inadequate pilot judgment regarding the aircraft's operational limits during a high-bank, low-altitude maneuver.
- Impaired perception and decision-making, likely influenced by the pilot's emotional state and the high-stress environment.
- Organizational failures in managerial supervision, specifically the lack of formal performance evaluation tools and approved operational manuals.
- Lack of formal oversight regarding flight training, which allowed for the possibility of an unqualified pilot operating the specific aircraft type.
- Organizational culture characterized by informality, which contributed to the breakdown of established safety rules and procedures.