What happened
On November 24, 2018, an AW109SP helicopter, registration PT-FPS, crashed near Pico do Itapeva in Campos do Jordão, Brazil. The aircraft was performing a private flight from the Cristália Helipad in Itapira to an unregistered location in Campos do Jordão, carrying two crewmembers and four passengers.
During the flight, the aircraft entered a loss of control in flight. The helicopter struck the ground with high impact, resulting in the destruction of the aircraft and six fatalities (all occupants). The investigation revealed that the crew was attempting an uncertified instrument flight procedure and was operating in meteorological conditions that did not meet the minimum visibility and ceiling requirements for VFR operations.
The investigation
CENIPA's investigation focused on the pilot's qualifications and the aircraft's flight parameters. While the aircraft's systems and engines were found to be in good working order, investigators discovered that the pilot in command (PIC) lacked the necessary endorsement for the AW109SP model. Although the pilot had experience with the A109E variant, regulatory changes had transitioned the AW109SP from a "type" to a "class" rating, requiring a specific endorsement that was not present in the pilot's records.
Analysis of the flight data and wreckage suggested that the crew may have experienced spatial disorientation during a climb. The investigation noted that the pilot's lack of specific training for this model likely led to difficulties managing the aircraft's advanced automation, specifically the Torque Limiter function and the Automatic Flight Control System (AFCS). The crew's focus on a rapid climb likely led to a reduction in airspeed and a loss of situational awareness.
Findings
- Lack of proper training: The pilot in command did not possess the required endorsement for the AW109SP, which created gaps in the knowledge and skills necessary to manage the aircraft's specific systems.
- Spatial disorientation: Adverse weather and restricted visibility contributed to the crew losing their orientation, leading to a loss of control.
- Inadequate flight planning: The crew utilized an uncertified procedure and failed to properly assess the meteorological conditions for the route.
- Organizational oversight: The operator's processes failed to verify the pilot's specific qualifications for the aircraft model being operated.