What happened
On January 15, 2010, an HB-3/350B helicopter, registration PT-HLE, departed from Tapauá, Amazonas, bound for Lábrea, Amazonas. The aircraft was operated by JVC Aerotáxi LTDA and was carrying a pilot and one passenger.
At approximately 20:22 UTC, the aircraft's satellite tracking system (SPOT) transmitted its last known position near Canutama, Amazonas. Following the loss of signal, search and rescue operations were initiated by the aircraft owner the following day. Despite extensive efforts, the aircraft and its two occupants were not located, and the search operation was suspended after twenty days. The aircraft and its occupants were officially declared missing.
The investigation
CENIPA's investigation focused on the circumstances leading to the disappearance, as there were no witnesses and the wreckage could not be found. Investigators analyzed meteorological data, which indicated that the flight path was subject to severe weather, including thunderstorms and heavy rain.
The investigation examined the pilot's professional background, noting his extensive experience in the Amazon region but also identifying that his instrument flight rating had been expired since 2006. Furthermore, the aircraft was not certified for instrument flight rules (IFR). The investigation also looked into the company's organizational culture, specifically its approach to flight supervision and operational discipline.
Findings
- Inadequate flight planning: The pilot failed to adequately analyze the meteorological conditions, which were extremely unfavorable for visual flight rules (VFR) at the time of departure.
- Adverse weather: The aircraft likely encountered heavy cloud cover and thunderstorms, potentially forcing the pilot into an uncontrolled flight situation while attempting to fly by instruments in a non-IFR certified aircraft.
- Excessive self-confidence: The pilot's vast experience in the region may have led to an overestimation of his ability to navigate through severe weather.
- Organizational failures: The operator's culture of "conscious discipline" lacked effective supervision. The company permitted the pilot to file flight plans for destinations different from the actual intended route and allowed the use of a handheld GPS as the primary means of navigation without updated waypoints.
- Lack of technical support: The flight coordination sector lacked qualified personnel to assist the pilot with weather analysis or to discourage the decision to proceed under dangerous conditions.