What happened
On July 12, 2010, an R22 helicopter, registration PT-YBF, was conducting a primary flight instruction mission at Jacarepaguá Aerodrome (SBJR) in Rio de Janeiro. The flight, operated by Nacional Escola de Pilotagem Ltda., included an instructor and a student pilot.
During a low-altitude hover training exercise, the instructor attempted to transfer flight controls to the student. At approximately one meter above the ground, the aircraft experienced a pendulum motion and lateral displacement. The left skid made contact with the ground, causing the main rotor blades to strike the terrain and the aircraft to overturn onto its left side. Both occupants escaped the wreckage uninjured, though the aircraft sustained severe damage to the transmission, tail cone, cabin, and windshield.
The investigation
CENIPA's investigation focused on the sequence of events during the control transfer and the physiological state of the crew. The investigation examined the instructor's workload, noting he was performing his seventh instructional flight of the day and had reported feeling fatigued. The investigation also looked into the ergonomic characteristics of the R22's cyclic control, which features a dual-handle pendular bar, and how manual inputs during control transfers can destabilize the aircraft.
Investigators found that the instructor was simultaneously managing administrative roles as an operations director and chief pilot, which contributed to his fatigue. Furthermore, the investigation identified a lack of standardized communication procedures between instructors and students regarding the handover of controls.
Findings
- Loss of coordination: A failure in cockpit coordination occurred when the student did not realize the instructor was transferring control, leaving the aircraft momentarily without active command.
- Pilot fatigue: The instructor's fatigue, resulting from a heavy daily flight load and dual administrative/operational responsibilities, likely degraded his situational awareness and altitude perception.
- Improper altitude management: The instructor's judgment was compromised, leading to the exercise being performed at an altitude lower than recommended.
- Lack of standardized procedures: The flight school lacked formal protocols for identifying pilot fatigue and had no standardized communication or verification (call-and-response) procedures for transferring flight controls.