What happened
On November 25, 2022, an AS365 N2 helicopter, registration PS-MEK, was conducting a ferry flight from São Salvador do Tocantins to Palmas, Tocantins. The flight, operated by Ambipar Flyone Serviço Aéreo Especializado, Comércio e Serviços S.A., initially departed from a stadium area but was interrupted when the pilot performed a gear-up landing at the same location due to deteriorating weather.
After remaining overnight, the pilot attempted the flight again. During this second departure, the aircraft encountered a convective system characterized by intense cloud development, thunderstorms, and heavy wind gusts. While attempting to maintain visual contact with the ground by flying at a very low altitude, the aircraft inadvertently entered instrument meteorological conditions (IMC). During a steep left turn at low level, the aircraft lost altitude and collided with the terrain in a rural area. The impact caused substantial damage to the entire structure, including the engines and transmission.
The investigation
CENIPA's investigation established that the pilot was not qualified to conduct the flight, as they had not completed the company's required Operational Training Program (OTP) and held an expired instrument rating. The investigation also examined the meteorological data from the GOES-16 satellite, which confirmed the presence of a severe convective system over the flight path. Investigators analyzed the aircraft's flight path and the pilot's decision-making process, noting that the pilot attempted to fly at low altitudes to maintain visual references despite the deteriorating weather.
Findings
- The pilot's decision to continue the flight in adverse weather, combined with an inappropriate decision-making process and inadequate risk assessment.
- The pilot was not legally qualified for the flight due to incomplete company training and an expired IFR rating.
- The presence of severe meteorological conditions, including thunderstorms and heavy wind gusts, which forced the aircraft into IMC.
- The pilot's attempt to maintain visual reference by flying at low altitudes, which reduced safety margins and contributed to the terrain impact.
- Organizational deficiencies, including a lack of oversight regarding crew qualifications and a culture that may have tolerated operational deviations.
- Potential spatial disorientation and improper use of flight controls during a high-rate turn preceding the impact.