What happened
On October 28, 2008, a Bell 206B helicopter, registration PT-YBB, was performing a ferry flight from Araucária, PR, to Porto Alegre, RS. The flight included an unscheduled intermediate stop at a farm in Lages, SC, to refuel the aircraft using plastic containers.
Following the refueling process, the pilot initiated takeoff from the non-certified landing site. Shortly after departing, the pilot reported hearing a loud noise coming from the upper section of the cabin. In an attempt to land and investigate the source of the noise, the pilot lost control of the aircraft, resulting in a high-impact collision with the ground. The aircraft sustained substantial damage to the engine, rotor blades, tail cone, and airframe. The pilot sustained light injuries.
The investigation
CENIPA investigators examined the wreckage and conducted technical analyses of the aircraft components. The engine was sent to Rolls Royce do Brasil for inspection to identify any potential pre-existing failures. Technical reports from the engine analysis and inspections of the airframe and rotor systems found no evidence of mechanical or system failures that could have contributed to the accident.
Investigators also reviewed the operational procedures regarding the transport of flammable liquids. The investigation noted that the fuel was being transported in plastic containers, which did not comply with the safety regulations for transporting dangerous goods (IAC 153-1001/2005) in effect at the time. Furthermore, the refueling operation was conducted without ground support or a certified landing site, creating a high-risk environment.
Findings
- Improper handling of controls: Since no mechanical failure was identified, the investigation concluded that the most probable cause was an operational error in the application of flight controls during the emergency maneuver.
- Inadequate management supervision: The operator's oversight was insufficient, as it allowed a flight plan to proceed involving an uncertified landing site, improper transport of flammable materials, and refueling without ground assistance.
- Operational non-compliance: The flight planning demonstrated a lack of adherence to safety principles, characterized by the pilot's acceptance of a high-risk mission and the improper transport of hazardous materials.