What happened
On December 4, 2016, a Robinson R44 II helicopter, registration PR-TUN, crashed into a wooded area in the municipality of São Lourenço da Serra, São Paulo. The flight originated from the Osasco Helipad, destined for a private event at a party house. Approximately 30 minutes into the flight, the aircraft experienced a loss of control in-flight and struck the ground. The impact destroyed the aircraft and resulted in four fatalities, including the pilot and three passengers.
The investigation
CENIPA investigators reconstructed the flight sequence using data from a GoPro camera carried by a passenger, which recorded the moments leading up to the impact. The investigation established that while the aircraft's engine and transmission were functioning correctly, the pilot performed a maneuver involving high load factors by applying cyclic input to the right and back. This caused the rotor RPM to drop, triggering the LOW RPM warning light.
Investigators also examined the pilot's recent activity, noting that he had performed several flights earlier that day, including coverage for a show at the Anhemly Sambadrome, which may have contributed to fatigue. Meteorological data confirmed that the aircraft encountered light to moderate rain and clouds, leading to a loss of visual references. The investigation also noted that the pilot's professional routine involved an informal working relationship with the operator, which lacked standardized oversight.
Findings
- Spatial disorientation caused by the loss of visual references when the aircraft entered instrument meteorological conditions (IMC).
- Improper decision-making regarding the decision to continue the flight into adverse weather conditions without IFR certification.
- Flight indiscipline due to the failure to adhere to Visual Flight Rules (VFR) once visibility was restricted.
- Inadequate flight planning regarding the known meteorological conditions along the route.
- Potential fatigue resulting from a demanding flight schedule on the day of the accident.
- Excessive confidence in the ability to navigate adverse conditions despite the lack of technical qualification for IMC flight.