What happened
On 15 July 2011, an AS350B2 helicopter, registration PR-JGM, crashed into a hill in a mountainous area near Ribeirão das Almas, in the state of Santa Catarina. The flight, operated by Nanete Textil Ltda., departed from a private helipad in Jaraguá do Sul at approximately 12:22 UTC, bound for Navegantes.
Roughly three minutes after takeoff, the aircraft struck trees at an elevation of 1,700 feet at a 45-degree pitch-down angle. The impact destroyed the aircraft, and all three occupants—the pilot and two passengers—perished in the accident. Evidence from the wreckage indicated that the engine was producing power at the moment of impact.
The investigation
CENIPA's investigation established that the aircraft was operating under Visual Flight Rules (VFR), but meteorological conditions at the time were unfavorable for such operations. Low layers of clouds were present between 600 and 700 feet, with another layer at 1,300 feet, effectively placing the flight in Instrument Meteorological Conditions (IMC). The pilot was not IFR-rated, and the aircraft was not certified for IFR flight.
The investigation also examined the operational environment. It was found that the pilot was under significant professional pressure due to a strained relationship with the aircraft owner, who was described as authoritarian. This interpersonal dynamic, combined with the pilot's need to maintain employment to support his family, likely influenced his decision-making. Furthermore, the departure site was being used without proper registration or completed infrastructure verification by the regulatory agency.
Findings
- Adverse meteorological conditions: The flight proceeded into IMC despite the pilot lacking the necessary IFR rating and the aircraft lacking IFR certification.
- Impaired decision-making: The pilot failed to adequately evaluate operational risks and did not utilize available meteorological resources during flight planning.
- Organizational pressure: The pilot's judgment was likely compromised by stress and pressure exerted by the aircraft owner, leading to a state of complacency regarding safety.
- Lack of oversight: There was an absence of adequate supervision of flight activities and a lack of formal communication channels between the operator and the pilot.